Chapter 5160-3 Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Mentally Retarded

5160-3-01 Definitions.

Except as otherwise provided in Chapter 5101:3-3 of the Administrative Code:

(A) "Allowable costs" are those costs incurred for certified beds in a facility as determined by the Ohio department of job and family services (ODJFS) to be reasonable, as set forth under paragraph (AA) of this rule, and do not include fines paid under sections 5111.35 to 5111.62 , 5111.683 , and 5111.99 of the Revised Code. Unless otherwise enumerated in Chapter 5101:3-3 of the Administrative Code, allowable costs are also determined in accordance with the following reference material, as currently issued and updated, in the following priority:

(1) Title 42 Code of Federal Regulations (C.F.R.) Chapter IV (10/1/2005);

(2) The provider reimbursement manual (CMS publication 15-1, www.cms.hhs.gov/manuals); or

(3) Generally accepted accounting principles in accordance with standards prescribed by the "American Institute of Certified Public Accountants" (AICPA) as in effect on the effective date of this rule. These standards can be obtained at www.aicpa.org.

(B) "Ancillary and support costs" means costs as defined under rule 5101:3-3-42 of the Administrative Code.

(C) "Annual facility average case-mix score" is the score used to calculate the facility's cost per case-mix unit.

(D) "Capital costs" means costs of ownership and, in the case of an intermediate care facility for the mentally retarded, costs of nonextensive renovation.

(1) "Cost of ownership" means the actual expense incurred for all of the following:

(a) Depreciation and interest on any items capitalized including the following:

(i) Buildings;

(ii) Building improvements;

(iii) Equipment;

(iv) Extensive renovation;

(v) Transportation equipment;

(vi) Replacement beds;

(b) Amortization and interest on land improvements and leasehold improvements;

(c) Amortization of financing costs;

(d) Except as provided under paragraph (M) of this rule, lease and rent of land, building, and equipment.

(2) "Costs of nonextensive renovation" means the actual expense incurred for depreciation or amortization and interest on renovations that are not extensive renovations.

(E) "Capital lease" and "operating lease" shall be construed in accordance with generally accepted accounting principles.

(F) "Case mix score" means the measure of the relative direct-care resources needed to provide care and rehabilitation to a resident of a nursing facility (NFs) or intermediate care facility for the mentally retarded (ICFs-MR).

(G) "Cost of construction" means the costs incurred for the construction of beds originally contained in the NF or ICF-MR and the costs incurred for the construction of beds added to the NF or ICF-MR after the construction of the original beds. In the case of NFs or ICFs-MR which extensively renovate, "cost of construction" includes the costs incurred for the extensive renovation.

(H) "Cost per case mix unit" for NFs is determined at least once every ten years for a peer group and shall be used for subsequent years until the department redetermines it. Cost per case mix unit for ICFs-MR is determined annually. The "cost per case mix unit" is calculated by dividing the facility's desk-reviewed, actual, allowable, per diem direct care costs for the applicable calendar year preceding the fiscal year in which the rate will be paid by the facility's annual average case mix score for the applicable calendar year.

(I) "Date of licensure," for a facility originally licensed as a nursing home under Chapter 3721. of the Revised Code, means the date specific beds were originally licensed as nursing home beds under that chapter , regardless of whether they were subsequently licensed as residential facility beds. For a facility originally licensed as a residential facility, "date of licensure" means the date specific beds were originally licensed as residential facility beds under that section.

(1) If nursing home beds licensed under Chapter 3721. of the Revised Code or residential facility beds licensed under section 5123.19 of the Revised Code were not required by law to be licensed when they were originally used to provide nursing home or residential facility services, "date of licensure" means the date the beds first were used to provide nursing home or residential facility services, regardless of the date the present provider obtained licensure.

(2) If a facility adds nursing home or residential facility beds or in the case of an ICF-MR with more than eight beds or a NF, it extensively renovates the facility after its original date of licensure, it will have a different date of licensure for the additional beds or for the extensively renovated facility, unless, in the case of the addition of beds, the beds are added in a space that was constructed at the same time as the previously licensed beds but was not licensed under Chapter 3721. or section 5123.19 of the Revised Code at that time. The licensure date for additional beds or facilities which extensively renovate shall be the date the beds are placed into service.

(J) "Desk reviewed" means that costs as reported on a cost report have been subjected to a desk review and preliminarily determined to be allowable costs.

(K) "Direct care costs" means costs as defined under rules 5101:3-3-42 and 5101:3-3-71 of the Administrative Code.

(L) "Fiscal year" means the fiscal year of this state, as specified in section 9.34 of the Revised Code.

(M) "Indirect care costs" means costs as defined under rule 5101:3-3-71 of the Administrative Code.

(N) "Inpatient days" means all days during which a resident, regardless of payment source, occupies a bed in a NF or ICF-MR that is included in the facility's certified capacity under Title XIX of the "Social Security Act," 49 stat. 620 (1935), 42 U.S.C. 301 , as amended. Therapeutic or hospital leave days for which payment is made under section 5111.33 of the Revised Code are considered inpatient days proportionate to the percentage of the facility's per resident per day rate paid for those days.

(O) "Intermediate care facility for the mentally retarded" (ICF-MR) means an intermediate care facility for the mentally retarded certified as in compliance with applicable standards for the medical assistance program by the director of health in accordance with Title XIX of the "Social Security Act."

(P) "Maintenance and repair expenses" means expenditures, except as provided in paragraph (EE) of this rule, that are necessary and proper to maintain an asset in a normally efficient working condition and that do not extend the useful life of the asset two years or more. Maintenance and repairs expense may include, but are not limited to, the cost of ordinary repairs such as painting and wallpapering.

(Q) "Minimum data set " (MDS ) is the resident assessment instrument approved by the centers for medicare and medicaid services (CMS) as described in rule 5101:3-3-43.1 of the Administrative Code. The MDS provides the resident assessment data which is used to classify the resident into a resource utilization group in the RUG case-mix classification system as described in rule 5101:3-3-43.2 of the Administrative Code.

(R) "Nursing facility" (NF) means a facility, or a distinct part of a facility, that is certified as a nursing facility by the director of health in accordance with Title XIX of the "Social Security Act," and is not an intermediate care facility for the mentally retarded (ICF-MR). "Nursing facility" includes a facility, or a distinct part of a facility, that is certified as a nursing facility by the director of health in accordance with Title XIX of the "Social Security Act," and is certified as a skilled nursing facility by the director in accordance with Title XIX of the "Social Security Act."

(S) "Other protected costs" means costs as defined under rule 5101:3-3-71 of the Administrative Code.

(T) "Outlier" means residents who have special care needs as defined under rule 5101:3-3-17 of the Administrative Code.

(U) "Owner" means any person or government entity that has at least five per cent ownership or interest, either directly, indirectly, or in any combination, in a NF or ICF-MR.

(V) "Patient" includes resident or individual.

(W) "Provider" means a person or government entity that operates a NF or ICF-MR under a provider agreement.

(X) "Provider agreement" means a contract between ODJFS and an operator of a NF or ICF-MR for the provision of NF or ICF-MR services under the medical assistance program. The signature of the operator or the operator's authorized agent binds the operator to the terms of the agreement.

(Y) "Purchased nursing services" means services that are provided by registered nurses, licensed practical nurses, or nurse aides who are temporary personnel furnished by a nursing pool on behalf of the facility. These personnel are not considered to be employees of the facility.

(Z) "Quarterly facility average case-mix score" is the facility average case-mix score based on data submitted for one reporting quarter.

(AA) "Reasonable" means that a cost is an actual cost that is appropriate and helpful to develop and maintain the operation of patient care facilities and activities, including normal standby costs, and that does not exceed what a prudent buyer pays for a given item or services. Reasonable costs may vary from provider to provider and from time to time for the same provider.

(BB) "Related party" means an individual or organization that, to a significant extent, has common ownership with, is associated or affiliated with, has control of, or is controlled by, the provider, as detailed below:

(1) An individual who is a relative of an owner is a related party.

(2) Common ownership exists when an individual or individuals possess significant ownership or equity in both provider and the other organization. Significant ownership or equity exists when an individual or individuals possess five per cent ownership or equity in both the provider and a supplier. Significant ownership or equity is presumed to exist when an individual or individuals possess ten per cent ownership or equity in both the provider and another organization from which the provider purchases or leases real property.

(3) Control exists when an individual or organization has the power, directly or indirectly, to significantly influence or direct the actions or policies of an organization.

(4) An individual or organization that supplies goods or services to a provider shall not be considered a related party if all the following conditions are met:

(a) A supplier is a separate bona fide organization;

(b) A substantial part of the supplier's business activity of the type carried on with the provider is transacted with others than the provider and there is an open, competitive market for the types of goods or services the supplier furnishes;

(c) The types of goods or services are commonly obtained by other NFs or ICFs-MR from outside organizations and are not a basic element of patient care ordinarily furnished directly to patients by the facilities;

(d) The charge to the provider is in line with the charge for the goods or services in the open market and no more than the charge made under comparable circumstances to others by the supplier.

(5) The amount of indirect ownership is determined by multiplying the percentage of ownership interest at each level (e.g., forty per cent interest in corporation "A" which owns fifty per cent of corporation "B" results in a twenty per cent indirect interest in corporation "B").

(6) If a provider transfers an interest or leases an interest in a facility to another provider who is a related party, the capital cost basis shall be adjusted for a sale of a facility to or a lease to a provider that is not a related party if all of the following conditions are met:

(a) For a NF transfer:

(i) The related party is a relative of owner.

(ii) The provider making the transfer retains no interest in the facility except through the exercise of the creditor's rights in the event of default.

(iii) ODJFS determines that the transfer is an arm's length transaction if all the following apply:

(a) Once the transfer goes into effect, the provider that made the transfer has no direct or indirect interest in the provider that acquires the facility or the facility itself, including interest as an owner, officer, director, employee, independent contractor, or consultant, but excluding interest as a creditor. If the provider making the transfer maintains an interest as a creditor, the interest rate of the creditor shall not exceed the lesser of:

(i) The prime rate, as published by the "Wall Street Journal" on the first business day of the calendar year, plus four per cent; or

(ii) Fifteen per cent.

(b) The provider that made the transfer does not reacquire an interest in the facility except through the exercise of a creditor's rights in the event of a default. If the provider reacquires an interest in the facility in this manner, ODJFS shall treat the facility as if the transfer never occurred when ODJFS calculates its reimbursement rates for capital costs.

(c) The provider transferring their facility shall provide ODJFS with certified appraisal(s) at least ninety days prior to the actual change of provider agreement(s). The certified appraisal(s) shall be conducted no earlier than one hundred eighty days prior to the actual change of provider agreement(s) for each facility transferred to a related party.

(iv) Except in the case of hardship caused by a catastrophic event, as determined by ODJFS, or in the case of a provider making the transfer who is at least sixty-five years of age, not less than twenty years have elapsed since, for the same facility, the capital cost basis was determined or adjusted most recently; or actual, allowable cost of ownership was determined most recently.

(b) For a NF lease:

(i) The related party is a relative of owner.

(ii) The lessor retains an ownership interest in only real property and any improvements on the real property except when a lessor retains ownership interest through the exercise of a lessor's rights in the event of default.

(iii) ODJFS determines that the lease is an arm's length transaction if all the following apply:

(a) Once the lease goes into effect, the lessor has no direct or indirect interest in the lessee or, except as provided in this rule, the facility itself, including interest as an owner, officer, director, employee, independent contractor, or consultant, but excluding interest as a lessor.

(b) The lessor does not reacquire an interest in the facility except through the exercise of a lessor's rights in the event of a default. If the lessor reacquires an interest in the facility in this manner, ODJFS shall treat the facility as if the lease never occurred when ODJFS calculates its reimbursement rates for capital costs.

(c) A lessor that proposes to lease a facility to a relative of owner shall obtain a certified appraisal(s) for each facility leased. The lessor of the facility shall provide ODJFS with certified appraisal(s) at least ninety days prior to the actual change of provider agreement(s). The certified appraisal(s) shall be conducted no earlier than one hundred eighty days prior to the actual change of provider agreement(s) for each facility leased to a related party.

(iv) Except in the case of hardship caused by a catastrophic event, as determined by ODJFS, or in the case of a lessor who is at least sixty-five years of age, not less than twenty years have elapsed since, for the same facility, the capital cost basis was determined or adjusted most recently; or actual, allowable cost of ownership was determined most recently.

(v) The provisions set forth in this paragraph do not apply to leases of specific items of equipment.

(c) For an ICF-MR transfer:

(i) The related party is a relative of owner.

(ii) The provider making the transfer retains no interest in the facility except through the exercise of the creditor's rights in the event of default.

(iii) ODJFS determines that the transfer is an arm's length transaction if all the following apply:

(a) Once the transfer goes into effect, the provider that made the transfer has no direct or indirect interest in the provider that acquires the facility or the facility itself, including interest as an owner, officer, director, employee, independent contractor, or consultant, but excluding interest as a creditor. If the provider making the transfer maintains an interest as a creditor, the interest rate of the creditor shall not exceed the lesser of:

(i) The prime rate, as published by the "Wall Street Journal" on the first business day of the calendar year plus four per cent; or

(ii) Fifteen per cent.

(b) The provider that made the transfer does not reacquire an interest in the facility except through the exercise of a creditor's rights in the event of a default. If the provider reacquires an interest in the facility in this manner, ODJFS shall treat the facility as if the transfer never occurred when ODJFS calculates its reimbursement rates for capital costs.

(c) The provider transferring their facility shall provide ODJFS with certified appraisal(s) at least ninety days prior to the actual change of provider agreement(s). The certified appraisal(s) shall be conducted no earlier than one hundred eighty days prior to the actual change of provider agreement(s) for each facility transferred to a related party.

(iv) Except in the case of hardship caused by a catastrophic event, as determined by ODJFS, or in the case of a provider making the transfer who is at least sixty-five years of age, not less than twenty years have elapsed since, for the same facility, the capital cost basis was determined or adjusted most recently; or actual, allowable cost of ownership was determined most recently.

(d) For an ICF-MR lease:

(i) The related party is a relative of owner.

(ii) The lessor retains an ownership interest in only real property and any improvements on the real property except when a lessor retains ownership interest through the exercise of a lessor's rights in the event of default.

(iii) ODJFS determines that the lease is an arm's length transaction if all the following apply:

(a) Once the lease goes into effect, the lessor has no direct or indirect interest in the lessee or, except as provided in this rule, the facility itself, including interest as an owner, officer, director, employee, independent contractor, or consultant, but excluding interest as a lessor.

(b) The lessor does not reacquire an interest in the facility except through the exercise of a lessor's rights in the event of a default. If the lessor reacquires an interest in the facility in this manner, ODJFS shall treat the facility as if the lease never occurred when ODJFS calculates its reimbursement rates for capital costs.

(c) A lessor that proposes to lease a facility to a relative of owner shall obtain a certified appraisal(s) for each facility leased. The lessor of the facility shall provide ODJFS with certified appraisal(s) at least ninety days prior to the actual change of provider agreement(s). The certified appraisal(s) shall be conducted no earlier than one hundred eighty days prior to the actual change of provider agreement(s) for each facility leased to a related party.

(iv) Except in the case of hardship caused by a catastrophic event, as determined by ODJFS, or in the case of a lessor who is at least sixty-five years of age, not less than twenty years have elapsed since, for the same facility, the capital cost basis was determined or adjusted most recently; or actual, allowable cost of ownership was determined most recently.

(v) The provisions set forth in this paragraph do not apply to leases of specific items of equipment.

(e) The provider shall notify ODJFS in writing and shall supply sufficient documentation demonstrating compliance with the provisions of this rule no less than ninety days before the anticipated date of completion of the transfer or lease. In the case of a transaction completed before December 28, 2000 and subject to CMS approval the provider shall supply sufficient documentation demonstrating compliance with the provisions of this rule within thirty days of the effective date of this rule. If the provider does not supply any of the required information, the provider shall not qualify for a rate adjustment. ODJFS shall issue a written decision determining whether the transfer meets the requirements of this rule within sixty days after receiving complete information as determined by ODJFS.

(f) Subject to approval by CMS of a state plan amendment authorizing such, the provisions of paragraph (BB)(6) of this rule shall apply to any transfer or lease that meets the requirements specified in paragraph (BB)(6) of this rule that occurred prior to December 28, 2000. Any rate adjustments which result from the provisions contained in paragraph (BB)(6) of this rule shall take effect as specified in rule 5101:3-3-24 of the Administrative Code, following a determination by ODJFS that the requirements of paragraph (BB)(6) of this rule are met. A provider seeking a determination from ODJFS that a transaction occurring prior to December 28, 2000, meets the requirements of this rule shall submit the necessary documentation under paragraph (BB)(6)(e) of this rule no later than thirty days after the effective date of this rule.

(CC) "Relative of owner" means an individual who is related to an owner of a NF or ICF-MR by one of the following relationships:

(1) Spouse;

(2) Natural parent, child, or sibling;

(3) Adopted parent, child, or sibling;

(4) Stepparent, stepchild, stepbrother, or stepsister;

(5) Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law;

(6) Grandparent or grandchild;

(7) Foster parent, foster child, foster brother, or foster sister.

(DD) "Extensive renovation" means a renovation that costs more than sixty-five per cent and no more than eighty-five per cent of the cost of constructing a new bed and that extends the useful life of the assets for at least ten years. To calculate the per-bed cost of a renovation project for purposes of determining whether it is an extensive renovation, the allowable cost of the project shall be divided by the number of beds in the facility certified for participation in the medical assistance program, even if the project does not affect all medicaid-certified beds. Allowable extensive renovations are considered an integral part of cost of ownership as set forth under paragraph (D)of this rule.

(1) For purposes of paragraph (DD) of this rule, the cost of constructing a new bed shall be considered to be forty thousand dollars, adjusted for inflation from January 1, 1993 to the end of the calendar year during which the renovation is completed using the consumer price index for shelter costs for all urban consumers for the north central region, as published by the United States bureau of labor statistics.

(2) ODJFS may treat a renovation that costs more than eighty-five per cent of the cost of constructing new beds as an extensive renovation if ODJFS determines that the renovation is more prudent than construction of new beds.

(EE) "Nonextensive renovation" means the betterment, improvement, or restoration of an ICF-MR beyond its current functional capacity through a structural change that costs at least five hundred dollars per bed. To calculate the per-bed cost of a renovation project for purposes of determining whether it is a nonextensive renovation, the allowable cost of the project shall be divided by the number of beds in the facility certified for participation in the medical assistance program, even if the project does not affect all medicaid-certified beds. A nonextensive renovation may include betterment, improvement, restoration, or replacement of assets that are affixed to the building and have a useful life of at least five years. A nonextensive renovation may include costs that otherwise would be considered maintenance and repair expenses if they are included as part of the nonextensive renovation project and are an integral part of the structural change that makes up the nonextensive renovation project. Nonextensive renovation does not mean construction of additional space for beds that will be added to a facility's licensed or certified capacity. Allowable nonextensive renovations are not considered cost of ownership as set forth under paragraph (D) of this rule.

(FF) The definitions established in paragraphs (DD) and (EE) of this rule apply to "extensive renovations" and "nonextensive renovations" approved by ODJFS on or after July 1, 1993. Any betterments, improvements, or restorations of NFs or ICFs-MR for which construction is started before July 1, 1993, and that meet the definitions of extensive renovations or nonextensive renovations established by the rules of ODJFS in effect on December 22, 1992, shall be considered extensive renovations or nonextensive renovations. For purposes of renovations approved by ODJFS, "construction is started" means the date in which the actual construction work begins at the facility site.

(GG) "Replacement beds" are beds which are relocated to a new building or portion of a building attached to and/or constructed outside of the original licensed structure of a NF or ICF-MR. Replacement beds may originate from within the licensed structure of a NF or ICF-MR from another NF or ICF-MR. Replacement beds are eligible for the cost of ownership efficiency incentive ceiling which corresponds to the period the beds were replaced.

(HH) "RUGs" is the resource utilization groups system of classifying NF residents into case-mix groups as described in rule 5101:3-3-43.2 of the Administrative Code.

Effective: 10/01/2010
R.C. 119.032 review dates: 07/14/2010 and 10/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.20
Prior Effective Dates: 7/1/80, 8/1/84, 9/30/93 (Emer), 1/1/94, 11/1/95, 7/1/00, 12/28/00, 5/17/01, 9/30/01, 2/2/06, 12/31/06

5160-3-01.1 Authorization for the Ohio department of developmental disabilities (DODD) to administer the medicaid program for services provided by intermediate care facilities for the mentally retarded (ICFs-MR).

(A) The Ohio department of developmental disabilities (DODD), through an interagency agreement with the Ohio department of job and family services (ODJFS), administers the medicaid program for services provided by intermediate care facilities for the mentally retarded (ICFs-MR) on a daily basis in accordance with section 5111.91 of the Revised Code. DODD may develop rules and policies governing the administration of the ICF-MR program, which shall be filed in Chapter 5123:2-7 of the Administrative Code upon review and approval by ODJFS in compliance with 42 C.F.R. 431.10 .

(B) In collaboration with DODD, ODJFS shall create and implement oversight measures related to the ICF-MR program in accordance with Chapter 5111. of the Revised Code. Reviews may consist of, but are not limited to, physical inspections of records and sites where services are provided, and interviews of providers and recipients of ICF-MR services. ICF-MR providers shall provide any records related to the administration and/or provision of ICF-MR services to ODJFS, the center for medicare and medicaid services (CMS), the medicaid fraud control unit, and any of their designees in accordance with the medicaid provider agreement.

(C) ODJFS will monitor payment made under authority of this rule as necessary to ensure that funding is used for authorized purposes in compliance with federal and state laws, regulations, and policies governing the medicaid program. ODJFS and DODD may recover any overpayment identified by requesting voluntary repayment, or through provider payment offsets, or formal adjudicatory or non-adjudicatory recovery proceedings.

(D) Whenever an applicant for or recipient of ICF-MR services is affected by any action proposed or taken by DODD and/or ODJFS, the entity recommending or taking the action will provide medicaid due process in accordance with section 5101.35 of the Revised Code and as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code. Such actions may include, but are not limited to, the approval, denial, or termination of enrollment or a denial of ICF-MR services. If an applicant or enrollee requests a hearing related to an action taken by DODD, the participation of DODD is required during the hearing proceedings to justify the decision under appeal.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.226

5160-3-02 Provider agreements for nursing facilities (NFs).

In addition to provisions in rules 5101:3-3-02.1 and 5101:3-3-02.2 of the Administrative Code, execution and maintenance of a provider agreement between the Ohio department of job and family services (ODJFS) and the operator of a NF is also contingent upon compliance with requirements set forth in this rule.

(A) Definitions.

(1) "Closure" means the discontinuance of the use of the building or part of the building that houses the facility as a NF , and that results in the relocation of the facility's residents who continue to require NF services. If the building is converted to a different use and acquires a new type of license, residents who require services offered under the new license type may remain.

(a) A facility's closure occurs regardless of whether there is a replacement of the facility whereby the operator completely or partially replaces the facility's physical plant through the construction of a new physical plant or the transfer of the facility's license from one physical plant location to another.

(b) Facility closure occurs regardless of whether residents of the closing facility elect to be relocated to the operator's replacement facility or to another NF .

(c) A facility closure occurs regardless of action taken by the Ohio department of health (ODH) related to the facility's certification under Title XIX of the Social Security Act, 79 stat. 286 (1965), 42 U.S.C. 1396 , that may result in the transfer of part of the facility's survey findings to a replacement facility, or related to retention of a license as a NF under Chapter 3721. of the Revised Code .

(d) The last effective date of the provider agreement of a closed facility will be the date of the relocation of the last resident.

(2) "Continuing care" refers to the living setting that provides the individual with different types of care based on a resident's need over time and may include an apartment or lodging, meals, maintenance services, and when necessary, nursing home care. All services are provided on the premises of the continuing care community. The individual signs a contract that identifies the continuum of services to be covered by the individual's initial entrance fee and subsequent monthly charges. If a continuing care contract provides for a living arrangement that specifically states that all health care services including nursing home services are met in full, medicaid payment cannot be made for those services covered by the contract. If a continuing care contract provides for only a portion of the resident's health care services, that portion shall be deducted from the actual cost of nursing home care and medicaid shall pay the difference up to the medicaid maximum per diem. An individual who entered into a life care or continuing care contract may be eligible for medicaid under the conditions in rule 5101:1-39-02.2 of the Administrative Code.

(3) "Failure to pay" means that an individual has failed, after reasonable and appropriate notice, to pay or to have the medicare or medicaid program pay on the individual's behalf, for the care provided by the NF . An individual shall be considered to have failed to have the individual's care paid for when the individual has a medicaid application in pending status, if both of the following are the case:

(a) The individual's application, or a substantially similar previous application, has been denied by the county department of job and family services (CDJFS); and

(b) If the individual appealed the denial pursuant to division (C) of section 5101.35 of the Revised Code, the director of ODJFS upheld the denial.

(4) "Medicaid eligible" means an individual has been determined eligible by the CDJFS under Chapter 5101:1-39 of the Administrative Code and has been issued an effective date of health care coverage for the time period in question.

(5) "Operator" means the individual, partnership, association, trust, corporation, or other legal entity that operates a NF .

(6) "Voluntary withdrawal" means that the operator of a NF, in compliance with section 1919(c)(2)(F) of the Social Security Act, voluntarily elects to withdraw from participation in the medicaid program but chooses to continue providing services of the type provided by NFs.

(B) A provider of a NF shall:

(1) Execute the provider agreement in the format provided by ODJFS; and

(2) Apply for and maintain a valid license to operate if required by law; and

(3) Comply with the provider agreement and all applicable federal, state, and local laws and rules; and

(4) Keep records and file reports as required in rule 5101:3-3-20 of the Administrative Code; and

(5) Open all records relating to the costs of its services for inspection and audit by ODJFS and otherwise comply with rule 5101:3-3-20 of the Administrative Code; and

(6) Supply to ODJFS such information as the department requires concerning NF services to individuals who are medicaid eligible or who have applied to be medicaid recipients; and

(7) Unless the conditions described in paragraph (J) of this rule are applicable, retain as a resident in the NF any individual who is medicaid eligible, becomes medicaid eligible, or applies for medicaid eligibility. Residents in the NF who are medicaid eligible, become medicaid eligible, or apply for medicaid eligibility are considered residents in the NF during any absence for which bed-hold days are reimbursed in accordance with rule 5101:3-3- 16.4 of the Administrative Code; and

(8) Unless the conditions described in paragraph (J) of this rule are applicable, admit as a resident in the NF , an individual who is medicaid eligible, whose application for medicaid is pending, or who is eligible for both medicare and medicaid, and whose level of care determination is appropriate for the admitting facility. This applies only if less than eighty per cent of the total residents in the NF are recipients of medicaid.

(a) In order to comply with these provisions, the NF admission policy shall be designed to admit individuals sequentially based on the following:

(i) The requested admission date; and

(ii) The date and time of receipt of the request; and

(iii) The availability of the level of care or range of services necessary to meet the needs of the applicants; and

(iv) Gender: sharing a room with a resident of the same sex (except married couples who agree to share the same room.)

(b) The NF shall maintain a written list of all requests for each admission. The list shall include the name of the potential resident; date and time the request was received; the requested admission date; and the reason for denial if not admitted. This list shall be made available upon request to the staff of ODJFS, CDJFS, and ODH.

(c) The following are exceptions to paragraph (B)(8) of this rule:

(i) Bed-hold days are exhausted.

Medicaid eligible residents of NFs who are on hospital stays, visiting with family and friends, or participating in therapeutic programs and have exhausted coverage for bed-hold days under rule 5101:3-3-16.4 of the Administrative Code, must be readmitted to the first available semi-private bed in accordance with the provisions of rule 5101:3-3-16.4 of the Administrative Code; or

(ii) Facility is a county home.

Any county home organized under Chapter 5155. of the Revised Code may admit individuals exclusively from the county in which the county home is located; or

(iii) Facility has a religious sponsor.

Any religious or denominational NF that is operated, supervised, or controlled by a religious organization may give preference to persons of the same religion or denomination; or

(iv) NF has continuing care contracts.

A NF may give preference to individuals with whom it has contracted to provide continuing care.

(v) Prolonged "medicaid pending" application status.

A NF may decline to admit a medicaid applicant if that facility has a resident whose application was pending upon admission and has been pending for more than sixty days, as verified by the CDJFS. The NF shall submit the necessary documentation in a timely manner as required in rules 5101:3-3-15.1 and 5101:3-3-15.3 of the Administrative Code.

(9) Provide the following necessary information to ODJFS and CDJFS to process records for payment and adjustment:

(a) Submit the JFS 09401 "Facility/CDJFS Transmittal" (rev. 4/2011) to the CDJFS to inform the CDJFS of any information regarding a specific resident for maintenance of current and accurate records at the CDJFS and the facility; and

(b) For dates of service prior to July 1, 2005, submit the JFS 09400 "Nursing Facility Payment and Adjustment Authorization" (rev. 10/2012) directly to ODJFS to initiate, terminate, or adjust medicaid payment for a specific resident as required.

(c) For dates of service on or after July 1, 2005, a NF shall submit claims electronically to ODJFS as required in rule 5101:3-3-39.1 of the Administrative Code.

(10) Permit access to facility and records for inspection by ODJFS, ODH, CDJFS, representatives of the office of the state long-term care ombudsman, and any other state or local government entity having authority to inspect, to the extent of that entity's authority.

(11) In the case of a change of operator as defined in section 5111.65 of the Revised Code, follow the procedures in paragraphs (B)(11)(a) to (B)(11)(d) of this rule.

(a) The exiting operator or owner and entering operator must provide a written notice to ODJFS, as provided in section 5111.67 of the Revised Code, at least forty-five days prior to the effective date of any actions that constitute a change of operator for the NF , but at least ninety days if residents are to be relocated. An exiting operator that does not give proper notice is subject to the penalties specified in section 5111.28 of the Revised Code.

(b) The entering operator must submit documentation of any transaction (e.g., sales agreement, contract, or lease) as requested by ODJFS to determine whether a change of operator has occurred as specified in section 5111.67 of the Revised Code.

(c) The entering operator shall submit an application for participation in the medicaid program and a written statement of intent to abide by ODJFS rules, the provisions of the assigned provider agreement, and any existing CMS 2567 "Statement of Deficiencies and Plan of Correction" (rev. 2/1999) submitted by the exiting operator.

(d) An entering operator is subject to the same survey findings as the exiting operator unless the entering operator does not accept assignment of the exiting operator's provider agreement. Refusal to accept assignment results in termination of certification on the last day of the exiting operator's participation in medicaid. An entering operator who refuses assignment may reapply for medicaid participation and must undergo a complete initial certification survey by ODH. There may be gaps in medicaid coverage at the facility.

(12) Ensure the security of all personal funds of residents in accordance with rule 5101:3-3- 16.5 of the Administrative Code.

(13) Comply with Title VI and Title VII of the Civil Rights Act of 1964 and Public Law 101-336 (the Americans with Disabilities Act of 1990), and shall not discriminate against any resident on the basis of race, color, age, sex, creed, national origin, or disability.

(14) Provide notice to ODJFS within thirty days of any bankruptcy or receivership pertaining to the provider. Notice shall be mailed to: "Office of Legal Services, Ohio Department of Job and Family Services, 30 East Broad Street-31st. Floor, Columbus, Ohio 43215-3414" and to: "Office of the Attorney General, 150 East Gay Street, 21st Floor, Columbus, Ohio 43215."

(C) A provider of a NF shall:

(1) Provide a statement to the individual explaining the individual's obligation to reimburse the cost of care provided during the medicaid application process if it is not covered by medicaid.

(2) Comply with the requirements in rule 5101:3-3-04.1 of the Administrative Code and repay ODJFS the federal share of payments under the circumstances required by sections 5111.45 and 5111.58 of the Revised Code.

(3) During a closure or voluntary withdrawal from the medicaid program provide ODJFS, the resident or guardian, and the residents' sponsors a written notice at least ninety days prior to the closure or voluntary withdrawal. A NF that does not issue the proper notice is subject to the penalties specified in section 5111.28 of the Revised Code.

(4) Comply with the following requirements when voluntarily withdrawing from the medicaid program:

(a) Continue to provide NF services to residents of the facility who were residing in the facility on the day before the effective date of the withdrawal (including those residents who were not entitled to medical assistance as of such day).

(i) A NF operator's voluntary withdrawal from participation in the medicaid program is not an acceptable basis for the transfer or discharge of these residents.

(ii) Nothing in this provision invalidates other legal grounds for NF-initiated discharge of medicaid residents after the effective date of withdrawal.

(b) Provide residents admitted after the effective date of withdrawal with information that the facility is not participating in the medicaid program with respect to those residents.

(c) Provide notice to ODJFS within fourteen days after the last medicaid funded resident has been relocated.

(D) A provider of a NF shall not:

(1) Charge fees for the application process of a medicaid individual or applicant.

(2) Charge a medicaid individual an admission fee.

(3) Charge a medicaid individual an advance deposit. However, a NF may charge an individual whose medicaid eligibility is pending, typically in the form of a pre-admission deposit or payment for services after admission. A NF that has charged a resident for services between the first month of eligibility established by the state and the date notice of eligibility is received is obligated to refund any payments received for that period less the state's determination of any resident's share of the NF costs for that same period.

(4) Require a third party to accept personal responsibility for paying the facility charges out of his or her own funds. However, the facility may require a representative who has legal access to an individual's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the individual's income or resources if the individual's medicaid application is denied and if the individual's cost of care is not being paid by medicare or another third-party payor. A third-party guarantee is not the same as a third-party payor (i.e., an insurance company), and this provision does not preclude the facility from obtaining information about medicare and medicaid eligibility or the availability of private insurance. The prohibition against third-party guarantees applies to all individuals and prospective individuals in all certified NFs regardless of payment source. This provision does not prohibit a third party from voluntarily making payment on behalf of an individual.

(E) ODJFS shall:

(1) Execute a provider agreement in accordance with the certification provisions set forth by the secretary of health and human services and ODH.

(2) In the case of a change of operator, issue an assigned provider agreement to the entering operator contingent upon the entering operator's compliance with paragraph (B)(11)(c) of this rule.

(3) Whenever ODJFS files a proposed rule, or proposed rule in revised form under division (D) of section 111.15 , or division (B) of section 119.03 of the Revised Code, ODJFS shall notify affected persons by posting on the ODJFS website the full text of rules governing the facility's participation as a medicaid provider. ODJFS may also send an email notice of the rule action to all persons whose name or contact information appears on a distribution list maintained by ODJFS. Persons may voluntarily submit an email address on an ODJFS maintained website in order to receive electronic communications regarding proposed rule actions. ODJFS shall maintain the electronic distribution list; however, the sole responsibility of the validity of any email address maintained on the distribution list is that of the person who submitted the email address.

(4) Make payments in accordance with Chapter 5111. of the Revised Code and Chapter 5101:3-3 of the Administrative Code to the NF for services to individuals eligible and approved for payment under the medicaid program.

(F) ODJFS may terminate, suspend, not enter into, or not renew, the provider agreement upon thirty days written notice to the provider for violations of Chapter 5111. of the Revised Code; Chapters 5101:3-1 and 5101:3-3 of the Administrative Code; and if applicable, subject to Chapter 119. of the Revised Code.

(G) Any NF violating provisions defined in paragraphs (B)(7) and (B)(8) of this rule will be subject to a penalty in accordance with provisions of section 5111.99 of the Revised Code.

(H) The CDJFS shall use the JFS 09401 to communicate with NFs regarding the assessment of payment for specific individuals.

(I) Exclusions.

The provisions of paragraphs (B)(7) and (B)(8) of this rule do not require an individual to be admitted or retained at the NF if the individual meets one of the following:

(1) The individual requires a level of care or range of services that the NF is not certified or otherwise qualified to provide; or

(2) The individual has a medicaid application in pending status and meets the definition of "failure to pay" in this rule.

Effective: 01/10/2013
R.C. 119.032 review dates: 07/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 3721.13 , 5111.01 , 5111.02 , 5111.22 , 5111.31 , 5111.65
Prior Effective Dates: 7/3/80, 7/7/80, 9/1/82, 11/10/83, 1/20/85 (Emer.), 7/1/85, 8/1/87, 9/30/87 (Emer.), 12/28/87, 3/30/88, 1/1/95, 7/1/97, 9/30/01, 7/1/03, 7/1/05, 8/1/09, 7/1/10

5160-3-02.1 Length and type of long term care provider agreements.

(A) Definitions.

(1) "Reasonable assurance period" means a certain period of time, determined by the centers for medicare and medicaid services (CMS), for which a long term care facility operator whose provider agreement has been involuntarily terminated is required to operate without recurrence of the deficiencies that were the basis for termination. Participation in the medicare and medicaid programs may resume only following that period. If corrections were made before submission of a new request for participation, the period of compliance before the new request is counted as part of the period.

(2) "State survey agency" means the agency that is under contract with the state medicaid agency and that inspects long term care facilities for the purposes of survey and certification. The state survey agency in Ohio is the Ohio department of health (ODH). The state medicaid agency in Ohio is the Ohio department of job and family services (ODJFS).

(B) Effective dates - skilled nursing facilities (SNFs), nursing facilities (NFs), and SNF/NFs.

(1) Initial certification of NFs and SNF/NFs.

(a) Effective dates of NF and SNF/NF provider agreements generally are assigned by the state survey agency on the basis of findings of compliance or substantial compliance with standards of certification.

(b) The effective date shall not be earlier than the date on which compliance is documented via the state survey agency's onsite visits to the institution.

(c) The effective date of a provider agreement of a nursing facility that participates in the medicaid program as a SNF/NF shall be the same as that of the facility's medicare provider agreement.

(2) NFs subsequently approved to operate as SNF/NFs.

(a) Upon approval from CMS of a NF to participate in the medicare program as a SNF/NF, ODJFS shall issue a SNF/NF provider agreement.

(b) The effective date of this provider agreement shall be the same as that of the facility's medicare provider agreement.

(3) Re-entry into the program following involuntary termination.

(a) Following involuntary termination of the medicaid provider agreement for a nursing facility, the provider agreement effective date of a facility re-entering the medicaid program shall be the same effective date as the date CMS issues for the facility's medicare provider agreement.

(b) Re-entry may occur only after the successful completion of a reasonable assurance period as determined by CMS.

(C) Term limits - NFs and SNF/NFs.

(1) The term of a provider agreement shall be based on the period of certification established by the state survey agency.

(2) The actual term of the agreement may be less than, but shall not exceed, the certification period recommended by the state survey agency.

(3) NFs and SNF/NFs.

(a) NFs and SNF/NFs are governed by open-end provider agreements.

(b) Open-end agreements have no specific expiration date.

(c) Continuation of an open-end provider agreement is contingent upon findings of continued compliance or substantial compliance with certification standards as determined by the state survey agency.

Replaces: 5101:3-3- 02.1

Effective: 01/10/2013
R.C. 119.032 review dates: 01/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.22 , 5111.31
Prior Effective Dates: 4/4/77, 12/30/77, 1/1/79, 3/23/79, 8/31/79, 11/1/79, 7/1/80, 7/7/80, 10/1/87, 1/1/95, 5/16/02, 9/29/05, 2/15/11

5160-3-02.2 Termination, denial, and non-renewal of long term care provider agreements.

(A) Written notice.

(1) The Ohio department of job and family services (ODJFS) may terminate, deny, or not renew a provider agreement upon thirty days written notice to the nursing facility (NF) .

(2) Notices and termination orders must comply with provisions set forth in sections 5111.06 and 5111.51 of the Revised Code.

(B) Reasons for which ODJFS may terminate, deny, or not renew a provider agreement.

(1) According to section 5111.22 of the Revised Code, ODJFS may terminate, deny, or not renew a provider agreement if ODJFS determines such an agreement is not in the best interests of the state or medicaid residents of long term care facilities.

(2) ODJFS may terminate, deny, or not renew a provider agreement on the basis of best interest including, but not limited to, the following reasons:

(a) The provider has not fully and accurately disclosed to ODJFS information as required by the provider agreement or any rule contained in division 5101:3 of the Administrative Code;

(b) The provider has failed to abide by or to have the capacity to comply with the terms and conditions of the provider agreement and/or rules and regulations promulgated by ODJFS;

(c) The provider has been found liable by a court for negligent performance of professional duties;

(d) The provider has failed to file cost reports as required according to rule 5101:3-3-20 of the Administrative Code;

(e) The provider has made false statements or has altered records, documents, or charts. Alteration does not include properly documented correction of records;

(f) The provider has failed to cooperate or provide requested records or documentation for purposes of an audit or review of any provider activity by any federal, state, or local agency;

(g) The provider has been found in violation of section 504 of the Rehabilitation Act of 1973, as amended; the Civil Rights Act of 1964, as amended; or Public Law 101-336 (the Americans with Disabilities Act of 1990) in relation to the employment of individuals, the provision of services, or the purchase of goods and services;

(h) The attorney general, auditor of state, or any board, bureau, commission, or department has recommended ODJFS terminate the provider agreement where the reason for the request bears a reasonable relationship to the administration of the medicaid program or the integrity of state and/or federal funds;

(i) The provider has violated the prohibition against billing medicaid residents for covered services or factoring as found in rule 5101:3-1-13.1 or 5101:3-1-23 of the Administrative Code;

(j) The facility has been found by the Ohio department of health (ODH) during a survey of the facility to have an emergency that is the result of a deficiency or cluster of deficiencies, and that constitutes immediate jeopardy;

(k) The provider does not comply with the requirements of section 5111.30 of the Revised Code for the installation of fire extinguishing and fire alarm systems, and with the requirements of section 3721.071 of the Revised Code for the submission of a written fire safety code; and

(l) The provider fails to pay the full amount of a franchise permit fee (FPF) pursuant to section 3721.541 of the Revised Code.

(C) Reasons for which ODJFS shall terminate, deny, or not renew a provider agreement.

(1) ODJFS shall terminate, deny, or not renew a provider agreement when any of the situations set forth in division (D) of section 5111.06 of the Revised Code occur including, but not limited to, the following:

(a) The provider has been terminated, suspended, or excluded by the medicare program and/or by the United States centers for medicare and medicaid services (CMS) and that action is binding on participation in the medicaid program or renders federal financial participation unavailable for participation in the medicaid program. Under these conditions, medicaid termination and payment sanction dates shall be the same as medicare termination and payment sanction dates;

(b) The facility has been decertified by the Ohio department of health (ODH) and/or the United States department of health and human services;

(c) The provider, or its owner, officer, authorized agent, associate, manager, or employee has pled guilty to or been convicted of a criminal offense, found liable in a civil action, or voluntarily settled a civil suit brought pursuant to section 109.85 of the Revised Code;

(d) The provider has committed medicaid fraud as defined in rule 5101:3-1-29 of the Administrative Code;

(e) The provider has pled guilty to or been convicted of a criminal activity materially related to either the medicare or medicaid program; or

(f) Any license, permit, or certificate that is required by ODJFS or the terms of the provider agreement has been denied, suspended, revoked, or not renewed.

(g) The provider has failed to ensure a nursing facility's full participation in the medicare program as a skilled nursing facility (SNF) pursuant to section 5111.21 of the Revised Code and rule 5101:3-3-02.4 of the Administrative Code.

(2) If ODH terminates certification of a facility, ODJFS shall terminate the facility's provider agreement pursuant to division (D) of section 5111.06 and division (B) of section 5111.52 of the Revised Code.

(D) Adjudication order.

(1) According to section 5111.06 of the Revised Code, ODJFS shall terminate, deny, or not renew an existing provider agreement by issuing an order pursuant to an adjudication conducted in accordance with Chapter 119. of the Revised Code, unless such action occurred as the result of events described in paragraph (C) of this rule.

(2) According to division (E) of section 5111.51 of the Revised Code, if ODJFS issues a termination order as the result of events set forth in paragraph

(B)

(2)

(j) of this rule, the termination may take effect prior to or during the pendency of the proceeding under Chapter 119. of the Revised Code.

(E) Impact of provider actions on CMS-imposed reasonable assurance periods.

(1) When seeking reentry to the medicaid program, providers are subject to procedures set forth in CMS publication 100-07 entitled "State Operations Manual" at Chapter 7 sections 7321B to 7321D (09/10/10) for SNFs and NFs, to comply with the provisions at 42 CFR 489.57 that govern reinstatement after termination, and require that the reason for termination of the previous agreement has been removed and there is reasonable assurance that it will not recur.

(2) After CMS has initiated involuntary termination action for a dually certified SNF/NF, or after ODH has initiated involuntary termination action for a medicaid-certified NF, a provider of a NF who is permitted to voluntarily terminate, voluntarily withdraw, or undergoes a change of operator, or the subsequent operator of the same facility, shall be subject to reasonable assurance requirements set by CMS when seeking reentry to the medicaid program.

(3) CMS or ODH initiates a termination action when it sends a provider the initial notice certifying noncompliance and proposing termination.

(4) Certification of noncompliance is a citation of noncompliance with a condition, or a nursing facility certification requirement cited at or above a scope level one and a severity level two pursuant to section 5111.35 of the Revised Code.

Effective: 01/10/2013
R.C. 119.032 review dates: 02/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 109.85 , 3721.071 , 3721.541 , 5111.01 , 5111.02 , 5111.03 , 5111.06 , 5111.22 , 5111.30 , 5111.31 , 5111.51 , 5111.52 , 5111.58 , 5111.60 , 5112.341
Prior Effective Dates: 4/7/77, 12/30/77, 1/1/79, 3/23/79, 8/31/79, 11/1/79, 7/1/80, 7/7/80, 10/1/87, 1/1/95, 5/16/02, 9/29/05, 2/15/11

5160-3-02.3 Institutions eligible to participate in medicaid as nursing facilities (NFs).

(A) Definitions.

(1) "Certification" means the process by which the state survey agency certifies its findings to the federal centers for medicare and medicaid services (CMS) or the Ohio department of job and family services (ODJFS) with respect to a facility's compliance with health and safety requirements of divisions (a), (b), (c), and (d) of section 1919 of the federal Social Security Act.

(2) "Certified beds" mean beds that are counted in a provider facility that meets medicaid standards. A count of facility beds may differ depending on whether the count is used for certification, licensure, eligibility for medicare or medicaid payment formulas, or other purposes.

(3) "Distinct part" means a portion of an institution or institutional complex that is certified to provide skilled nursing facility (SNF) and/or nursing facility (NF) services, or intermediate care facility for the mentally retarded (ICF-MR) services. A distinct part shall be physically distinguishable from the larger institution and fiscally separate for cost reporting purposes. A distinct part may be a separate building, wing, floor, hallway, or one side of a corridor. A hospital-based SNF or NF is a distinct part by definition. A long term care facility with both SNF and NF distinct parts is one facility, even though the distinct parts are certified separately for medicare and medicaid. "Distinct part", when applied to NFs or SNF/NFs, has the same definition and requirements as in 42 C.F.R. 483.5 .

(4) "Dually participating" means simultaneous participation of an institution or institutional complex in both the medicare and medicaid programs.

(5) "Dually participating long term care facility" means an institution that participates as both a SNF under the medicare program, and as a NF under the medicaid program. Such a facility is referred to as a SNF/NF.

(6) "Facility" means the entity subject to certification and approval in order for the provider to be approved for medicaid payment. A facility may be an entire institution such as a free-standing nursing home, or may be a distinct part of an institution such as a hospital or continuing care retirement community.

(7) "Long term care facility" means a NF, SNF, or dually participating SNF/NF as defined in division 5101:3 of the Administrative Code.

(8) "Long term care institutional services" means those medicaid funded, institutional medical, health, psycho-social, habilitative, rehabilitative, and/or personal care services that may be provided to eligible individuals in a NF or SNF/NF.

(9) "NF services" means those services available in institutions, or parts of institutions, that are certified as nursing facilities by ODH or by the state survey agency of another state.

(10) "Religious non-medical health care institution" (RNHCI) means an institution as defined in the Social Security Act, section 1861 (ss) (1), 79 Stat. 286 , 42 U.S.C. 1395x(ss) (1), , such as the "Christian Science RNHCIs" accredited by the "Commission for Accreditation of Christian Science Nursing Organizations/Facilities, Inc." RNHCIs are subject to conditions of participation in the medicaid program according to 42 C.F.R. 403 subpart G.

(11) "State survey agency" means the agency designated as the state health standard setting authority, and state health survey agency responsible for certifying and determining compliance of long term care facilities with the requirements for participation in the medicaid program. The state survey agency in Ohio is ODH.

(B) Types of long term care institutional services.

(1) The types of long term care institutional services covered in compliance with the provisions of division 5101:3 of the Administrative Code are NF services provided to eligible residents requiring either a skilled level of care as set forth in rule 5101:3-3-05 of the Administrative Code or an intermediate level of care as set forth in rule 5101:3-3-06 of the Administrative Code.

(2) Institutions not eligible for participation are:

(a) An institution licensed or approved as a tuberculosis hospital;

(b) A prison, juvenile criminal facility, or an institution used to incarcerate individuals involuntarily who have committed a violation of a criminal or civil law; and

(c) An institution for mental disease, as defined in rule 5101:3-3-06.1 of the Administrative Code, for persons under sixty-five years old.

(C) Requirements for participation.

To participate in the Ohio medicaid program and receive payment from ODJFS for long term care institutional services to eligible residents, operators of long term care facilities shall meet all of the following requirements:

(1) Operate an institution that meets the licensure, registration, and other applicable state standards as set forth in this rule; and

(2) Operate an institution certified by ODH or by the state survey agency of another state as being in compliance with applicable federal regulations for medicaid participation as a NF with a minimum of four NF certified beds; and

(3) Operate an institution for which a current, completed, and signed JFS 03623 "Ohio Medicaid Provider Agreement for Long Term Care Facilities (NFs and ICF-MRs)" (rev. 7/2007) is on file with ODJFS.

(D) Qualified types of Ohio NFs.

To be eligible for certification as a NF, an institution shall qualify as one of the following:

(1) A nursing home licensed by ODH under section 3721.02 of the Revised Code, or a nursing home licensed by a political subdivision certified under section 3721.09 of the Revised Code. Licensed nursing homes eligible for medicaid certification include:

(a) RHNCIs; and

(b) Veterans' homes operated under Chapter 5907. of the Revised Code; or

(2) A county home, county nursing home, or district home owned by the county and operated by the county commissioners in accordance with Chapter 5155. of the Revised Code, or operated by the board of county hospital trustees in accordance with section 5155.011 of the Revised Code; or

(3) A unit of any hospital registered under section 3701.07 of the Revised Code that contains beds categorized before August 5, 1989, as skilled nursing facility beds per section 3702.522 of the Revised Code; or

(4) A unit of any hospital registered under section 3701.07 of the Revised Code that contains beds categorized as long term care beds as defined in rule 3701-59-01 of the Administrative Code.

(E) Mandatory dual participation.

To participate as a NF, all Ohio facilities shall comply with the provisions in rule 5101:3-3-02.4 of the Administrative Code regarding dual participation in the medicare program as a SNF/NF.

(F) Certification of NFs and beds subject to certification survey.

(1) Certification.

A facility's certification as a NF by ODH or by the state survey agency of another state governs the types of services the operator of the facility may provide.

(2) Provider agreements.

(a) A provider agreement with the operator of an Ohio NF or SNF/NF shall include any part of the facility that meets standards for certification of compliance with federal and state laws and rules for participation in the medicaid program.

(b) Exceptions to this provision are NFs or SNFs that between July 1, 1987 and July 1, 1993 added beds licensed as nursing home beds under Chapter 3721. of the Revised Code. Such facilities are not required to include those beds in a provider agreement, unless otherwise required by federal law. This exception continues to apply if such facilities subsequently undergo a change of operator.

(3) Beds subject to certification survey.

(a) All beds in a medicaid participating NF or SNF/NF, except those licensed nursing home beds added between July 1, 1987 and July 1, 1993, shall be surveyed to determine compliance with the applicable certification standards and, if certifiable, included in the provider agreement as NF or SNF/NF beds.

(b) Beds that could quality as NF or SNF/NF beds and were added between July 1, 1987 and July 1, 1993 may be surveyed for compliance at the discretion of the operator. Such facilities are not required to include those beds in a provider agreement, unless otherwise required by federal law.

(c) All other beds that meet NF or SNF/NF standards shall be certified as NF or SNF/NF beds.

(4) The only other basis for allowing nonparticipation of a portion of an Ohio NF or SNF/NF that is not hospital-based is certification of noncompliance by ODH.

(G) Requirements for out-of-state providers of long term care institutional services.

(1) To participate in the Ohio medicaid program and receive payment from ODJFS for long term care institutional services to eligible Ohio residents, an operator of a long term care facility located outside Ohio shall meet all of the following requirements in their state of origin:

(a) The operator of the facility shall hold a valid state-required license, registration, or equivalent from the respective state that specifies the level(s) of care the facility is qualified to provide; and

(b) The operator of the facility shall hold a valid and current medicaid provider agreement from the respective state as a NF or SNF/NF provider type.

(2) Additionally, out-of-state providers shall meet the following Ohio requirements:

(a) The operator of the facility shall have a current, completed and signed JFS 03623 on file with ODJFS; and

(b) The operator of the facility shall obtain resident-specific and date-specific prior authorization from ODJFS in accordance with rule 5101:3-1-11 of the Administrative Code.

Effective: 01/10/2013
R.C. 119.032 review dates: 02/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.22 , 5111.31
Prior Effective Dates: 4/7/77, 7/1/80, 8/1/82, 1/30/85 (Emer.), 6/1/85, 9/30/87 (Emer.), 9/30/93 (Emer.), 1/1/94, 1/1/95, 7/1/00, 5/16/02, 7/1/03, 1/20/05, 9/29/05, 2/15/11

5160-3-02.4 Mandatory dual participation by nursing facilities (NFs) in the medicare program.

(A) Definitions.

(1) For purposes of this rule, the terms "certified beds," "distinct part," "dually participating," "facility," and "religious non-medical health care institution" (RNHCI) are defined in rule 5101:3-3-02.3 of the Administrative Code.

(2) For purposes of this rule, the term "reasonable assurance period" is defined in rule 5101:3-3-02.1 of the Administrative Code.

(3) "Fully participating" means participation of an institution in its entirety, either in the medicare or medicaid program, or both. A fully participating skilled nursing facility (SNF) is one in which every bed is certified for participation in medicare. A fully participating nursing facility (NF) is one in which every bed is certified for participation in medicaid. A fully participating SNF/NF is one in which every bed is certified for participation in both medicare and medicaid.

(B) Mandatory SNF participation and exceptions.

(1) Operators of Ohio NFs shall have all medicaid-certified beds as counted in the medicaid provider agreement also certified under medicare as SNF beds, in accordance with the provisions of this rule.

(2) Exceptions to mandatory SNF participation are:

(a) RNHCIs; and

(b) Veteran's homes operated under Chapter 5907. of the Revised Code; and

(c) A NF that has distinct part beds that are not required or permitted to participate in medicaid in accordance with paragraph (G) of rule 5101:3-3-02.3 of the Administrative Code or section 3702.522 of the Revised Code. These beds are excluded from the requirement to be both dually and fully participating SNF/NF certified beds.

(C) SNF/NFs that are both dually and fully participating are in compliance.

(1) Operators of Ohio NFs currently holding a medicaid provider agreement under which all medicaid-certified beds are also medicare-certified are in compliance with the requirement for NFs to be both dually and fully participating SNF/NFs.

(2) Pursuant to rule 5101:3-3-02.2 of the Administrative Code, the Ohio department of job and family services (ODJFS) shall terminate or not renew an operator's provider agreement if the provider fails to ensure a nursing facility's full participation in the medicare program as a SNF.

(D) Enrollment of new facilities in the medicaid program.

(1) Operators of Ohio facilities requesting participation in the medicaid NF program must provide documentation that they have requested full participation in the medicare SNF program.

(2) Operators of Ohio facilities requesting participation in the medicaid NF program that have been recommended for medicaid certification by the Ohio department of health (ODH) and that have provided documentation that they have requested full participation in the medicare SNF program, may be issued a fully participating NF medicaid provider agreement with an effective date determined in accordance with rule 5101:3-3-02.1 of the Administrative Code.

(3) After ODJFS is notified by the centers for medicare and medicaid services (CMS) that a facility operator's request for medicare certification has been approved, a SNF/NF provider agreement may be issued by ODJFS using the medicare SNF's effective date of certification in accordance with rule 5101:3-3-02.1 of the Administrative Code.

(4) If ODJFS is notified by CMS that a facility operator's request for medicare participation has been denied and all appeals have been exhausted, ODJFS shall terminate the NF's provider agreement in accordance with rule 5101:3-3-02.2 of the Administrative Code.

(E) Readmission of an Ohio facility to the medicaid program.

(1) A facility operator requesting readmission to the medicaid program must provide documentation of the request for admission or readmission and full participation in the medicare SNF program.

(2) If a facility's participation in the medicaid program ends due to voluntary withdrawal from participation by the operator, and the operator requests readmission to the medicaid NF program, enrollment will be processed in the same manner as for a new facility as set forth in paragraph (D) of this rule.

(3) If a facility's participation in the medicaid program ends due to involuntary termination, cancellation, or non-renewal by ODJFS, and ODH recommends that the facility receive certification, ODJFS may issue a provider agreement that begins on or after the effective date of medicare certification or recertification. If CMS has imposed a reasonable assurance period prior to re-entry to the medicare program, the reasonable assurance period also shall be imposed for medicaid enrollment purposes.

(F) Facilities undergoing a change of operator.

If a SNF/NF undergoes a change of operator that results in a change of provider agreement, the entering operator must either accept assignment of the exiting operator's provider agreement and survey results, or refuse assignment and undergo a new certification survey. An operator may accept or refuse assignment of the medicare provider agreement and/or the medicaid provider agreement.

(1) If an entering operator of a SNF/NF accepts assignment of both the medicare and medicaid provider agreements of the exiting operator, ODJFS shall issue a SNF/NF provider agreement to the entering operator. The entering operator must continue to operate a dually participating facility that fully participates in both the medicare and medicaid programs.

(2) If an entering operator of a SNF/NF refuses to accept assignment of the exiting operator's medicare provider agreement, but does accept assignment of the exiting operator's medicaid provider agreement, the entering operator must meet requirements for medicare participation in the same manner as for a new facility as set forth in paragraph (D) of this rule.

(3) If an entering operator of a SNF/NF refuses to accept assignment of the exiting operator's medicaid provider agreement, ODJFS shall terminate the agreement of the exiting operator. To enter the medicaid program, the entering operator must apply for medicaid participation as a new facility. Upon notice of certification approval from ODH, ODJFS may issue a medicaid provider agreement to the entering operator in the same manner as for new facilities as set forth in paragraph (D) of this rule.

Effective: 02/15/2011
R.C. 119.032 review dates: 11/19/2010 and 02/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 9/29/05

5160-3-02.7 Emergency management and resident relocation plan for nursing facilities (NFs).

(A) Purpose.

The purpose of this rule is to set forth provisions for the preparation for, response to, and recovery from an emergency at a NF . The provisions of this rule are in addition to the requirements set forth in sections 5111.51 , 5111.53 , and 5111.54 of the Revised Code, and in rule 3701-17-25 of the Administrative Code.

(B) Definitions.

"Emergency" means an unexpected situation or sudden occurrence of a serious or urgent nature that creates a substantial likelihood that one or more of a facility's residents may be seriously harmed if allowed to remain in the facility. Events that may constitute an emergency include, but are not limited to, the following:

(1) Tornado, severe wind, severe storm, flood, or other natural disaster; or

(2) Fire; or

(3) Explosion; or

(4) Loss of electrical power; or

(5) Release of hazardous chemicals or other hazardous material; or

(6) Civil disaster; or

(7) A labor strike that suddenly causes the number of staff members in a facility to be below that necessary for resident care.

(C) Written emergency relocation plan.

(1) Each provider shall have a written plan of procedure to be followed in the event of an emergency that requires relocation of residents.

(2) The plan must be clearly communicated and reviewed with all the facility's staff.

(D) Resident relocation components of emergency plan.

The emergency plan shall include all of the following components:

(1) Procedures for securing emergency shelter, including resident identification and tracking; and

(2) Procedures for resident care, including supplies, equipment, and staffing; and

(3) Procedures for contacting physicians, family, guardians, other individuals responsible for residents, and government agencies; and

(4) Procedures for resident transportation, hospitalization, therapy, and other appropriate services, including post-emergency transportation; and

(5) Procedures for records transfer.

(E) Notification.

(1) The provider shall notify all of the following:

(a) Residents' families. Each resident's family, guardian, sponsor, next of kin, or other person responsible for the resident; and

(b) County department of job and family services (CDJFS). The CDJFS shall be notified of the following within one working day after the relocation of residents:

(i) Nature of the emergency; and

(ii) Any injuries to residents; and

(iii) New location of residents who have been relocated; and

(iv) Plans for the restoration or rehabilitation of the facility to allow residents to re-occupy the facility; and

(v) An estimated timeframe for the resumption of operations, if applicable; and

(c) Ohio department of job and family services (ODJFS), bureau of long term services and supports (BLTSS) designated emergency coordinator. The BLTSS emergency coordinator shall be notified of the following within one working day after the relocation of residents:

(i) Nature of the emergency; and

(ii) Any significant injuries to residents related to the emergency that result in hospitalization; and

(iii) New location of residents who have been relocated; and

(iv) Plans for the restoration or rehabilitation of the facility to allow residents to re-occupy the facility; and

(v) An estimated timeframe for the resumption of operations, if applicable; and

(d) The Ohio department of health (ODH) within one working day after the relocation of residents.

(2) The provider shall submit weekly updates to the BLTSS emergency coordinator until the facility is permanently closed, residents are returned, or a partial evacuation has been resolved.

(F) Compliance and reimbursement.

The provider may consult with ODJFS regarding the functions that may be impaired by the temporary relocation of residents, including the following:

(1) Cost reporting; and

(2) Minimum data sets (MDS) reporting as it impacts case mix scores; and

(3) Level of care and pre-admission reviews for transferred residents; and

(4) Access to residents' personal needs allowance (PNA) accounts; and

(5) Claims processing.

(G) Termination of NF services.

Pursuant to section 5111.65 of the Revised Code, a NF closure does not occur if all of the facility's residents are relocated due to an emergency evacuation and one or more of the residents return to a medicaid-certified bed in the facility not later than thirty days after the evacuation occurs.

Effective: 01/10/2013
R.C. 119.032 review dates: 07/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.36
Rule Amplifies: 5111.21 , 5111.53
Prior Effective Dates: 1/1/80, 1/1/95, 5/16/02, 7/1/06, 7/1/10

5160-3-03.2 Resident protection fund (RPF) for nursing facilities (NFs) and collection of fines.

(A) Definitions.

(1) "Certification requirements" means the requirements with which a facility must be in compliance in order to be eligible to participate in the medicaid or medicare programs.

(2) "Deficiency" means a facility's failure to meet a participation requirement in the medicaid or medicare program.

(3) "Dually participating facility" means a facility that has a provider agreement in both the medicaid and medicare programs.

(4) "Fines" means civil monetary penalties (CMPs) imposed against a NF as a remedy for deficiencies or a cluster of deficiencies that were not substantially corrected before a survey.

(5) "Interest rate" means the rate determined by the tax commissioner on the fifteenth day of October each year by rounding the federal short-term rate to the nearest whole number per cent and adding three per cent. This is the interest rate per annum used in computing the interest that accrues during the following calendar year.

(6) "Noncompliance" means failure to substantially meet all applicable certification requirements.

(7) "Resident protection fund coordinator" means the Ohio department of job and family services (ODJFS) staff member who administers the resident protection fund.

(B) Methods for collection of fines from nursing facilities.

ODJFS shall collect CMP fines and interest through any of the following means:

(1) Lump sum payment.

A lump sum payment, including any interest accrued, from the provider; or

(2) Periodic payments.

Periodic payments, including any interest accrued, in accordance with a schedule approved by ODJFS for a period not to exceed twelve months; or

(3) Medicaid payment offset.

Following the date on which the fine plus interest becomes due, an appropriate reduction to medicaid payments made to the provider for care rendered to medicaid eligible residents in accordance with a schedule approved by ODJFS for a period not to exceed twelve months; or

(4) Attorney general's office (AGO).

If the facility is no longer active in the medicaid program, the fine may be referred to the AGO for collection in accordance with section 131.02 of the Revised Code.

(C) Procedure for collection of fines imposed by the Ohio department of health (ODH).

(1) ODH shall provide ODJFS with a copy of the letter issued to a facility regarding a final adjudication order imposing a fine for noncompliance with certification requirements.

(2) The letter ODH prepares shall contain the due date of the fine and the interest rate that will be assessed if not paid by the due date.

(3) The resident protection fund coordinator shall inform the NF, via certified mail, of payment options available.

(4) Not later than ten days after notification, the NF shall select a payment option and advise ODJFS in writing.

(5) If the NF fails to adhere to the terms of the payment agreement or fails to select a payment option within ten days, ODJFS shall immediately implement collection from an actively participating facility through medicaid payment offset(s).

(D) Procedure for collection of fines imposed by the centers for medicare and medicaid services (CMS) on a dually participating facility.

(1) If CMS has been unable to collect the fine directly, CMS shall send notification to ODJFS that contains the fine case number, the amount of the fine prorated to medicaid (determined by NF census on the date the fine begins to accrue), and the date the fine was due. The notification serves to notify ODJFS to collect the fine.

(2) The resident protection fund coordinator shall inform the NF, via certified mail, of the available payment options outlined in paragraph (B) of this rule.

(3) Not later than ten days after notification, the NF shall select a payment option and advise ODJFS in writing.

(4) If the NF fails to adhere to the terms of the payment agreement or fails to select a payment option within ten days, ODJFS shall immediately implement collection from an actively participating facility by medicaid payment offset(s).

(5) ODJFS shall retain the fine and any interest collected from the NF in the resident protection fund.

(6) The resident protection fund coordinator shall notify CMS in writing when the fine has been collected in full.

(E) Uses of the resident protection fund.

Proceeds from all fines, including interest collected, shall be deposited in the state treasury to the credit of the RPF.

Monies in the RPF shall be used for the protection of the health or property of residents of NFs in which ODH finds deficiencies, including the following uses:

(1) Payment for the costs of relocation of residents to other facilities; or

(2) Maintenance or operation of a facility pending correction of deficiencies or closure; or

(3) Reimbursement of residents for the loss of monies managed by the facility under rule 5101:3-3-16.5 of the Administrative Code.

(F) ODJFS shall provide budgetary, accounting, and other related management functions for the resident protection fund. When medicaid payment offset is used as a means of collection, the amount equal to the reduction in medicaid payments shall be deposited to the credit of the RPF.

(G) Procedure for ODJFS to obtain reimbursement or payment from the resident protection fund.

(1) The resident protection fund coordinator shall submit a report to the director of ODJFS setting forth the amount spent or to be spent by ODJFS on the activities listed in paragraph (E) of this rule.

(2) Upon approval of the report by the director of ODJFS, the resident protection fund coordinator shall submit a request to the treasurer of state to transfer funds from the RPF to ODJFS.

(H) Annual report.

The resident protection fund coordinator shall provide an annual report to the directors of ODJFS, ODH, and the Ohio department of aging (ODA). The report shall include the following information:

(1) A list of all fines deposited in the fund, and the names and addresses of the NFs that paid the fines; and

(2) A list, by type, of all expenditures of the resident protection fund.

(I) The provisions of this rule are applicable only to the extent that monies are available in the resident protection fund.

Replaces: 5101:3-3-63

Effective: 01/01/2009
R.C. 119.032 review dates: 01/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.36 , 5111.62
Rule Amplifies: 5111.01 , 5111.02 , 5111.35 to 5111.62
Prior Effective Dates: 1/1/95, 7/1/02, 7/1/05

5160-3-04 Payment during the Ohio department of medicaid (ODM) administrative appeals process for denial or termination of a provider agreement.

(A) When ODM is required to provide an adjudicatory hearing pursuant to Chapter 119. of the Revised Code, payment shall continue for medicaid-covered services provided to eligible residents during the appeal of, and the proposed termination or non-renewal of, a nursing facility (NF) provider agreement. Payment shall not be made under this provision for services rendered on or after the effective date of ODM issuance of a final order of adjudication pursuant to Chapter 119. of the Revised Code, except as provided in paragraph (B) of this rule.

(B) Payment may be provided up to thirty days following the effective date of termination or non-renewal of a NF provider agreement; or after an administrative hearing decision that upholds the ODM termination or non-renewal action. Payment will be available if both of the following conditions are met:

(1) Residents were admitted to the NF before the effective date of termination or expiration; and

(2) The NF cooperates with the state, local, and federal entities in the effort to transfer residents to other NFs, institutions, or community programs that can meet the residents' needs.

(C) When ODM acts under instructions from the United States department of health and human services, payment ends on the termination date specified by that agency.

Effective: 10/03/2014
Five Year Review (FYR) Dates: 07/01/2014 and 10/03/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.38 , 5165.35
Prior Effective Dates: 3/18/88 (Emer.), 6/16/88, 1/1/95, 7/1/2000, 7/1/03, 7/1/08, 1/10/13

5160-3-04.1 Payment to nursing facilities (NFs) during the survey agency's administrative appeals process.

(A) For the purposes of this rule, the following definitions shall apply:

(1) "State survey agency" means for the purpose of medicaid certification, the Ohio department of health (ODH).

(2) "Effective date of termination" means the date set by the state survey agency or the United States department of health and human services for the termination of certification.

(B) When medicaid certification is either terminated or not renewed, ODJFS must also either terminate or not renew the medicaid provider agreement.

(C) The following requirements apply:

(1) During the appeals process provided by the state survey agency for the proposed termination or non-renewal of certification, payment for covered services provided to eligible residents is available if:

(a) Payment is for those residents admitted prior to the effective date of an order issued under sections 5111.46 , 5111.48 , 5111.51 , and 5111.57 of the Revised Code, placing a ban on admissions to medicaid eligible residents and/or for certain diagnostic groups with specialized care needs; and

(b) The appeal is conducted prior to the effective date of termination or non-renewal.

(2) If the NF appeal process results in an adjudication order that upholds the ODH action or if the administrative hearing is not completed prior to the certification termination/non-renewal date, payment for services provided to eligible residents may be available for an additional thirty days if:

(a) The eligible resident was admitted prior to the termination/non-renewal date and prior to any ban on admissions as described in paragraph (C)(1)(a) of this rule; and

(b) The NF cooperates with the state, local, and federal entities in the effort to transfer residents to other NFs, institutions, or community programs that can meet the residents' needs.

(3) If a NF's appeal of the termination or non-renewal of its certification is upheld, payment for covered services provided to eligible residents is resumed. If the appeal decision is reached after the termination/ non-renewal date, payment is made retroactive to the date of termination.

(4) When the state survey agency certifies that there is jeopardy to residents' health and safety by issuing an order under Chapter 5111. of the Revised Code, or when it fails to certify that there is no jeopardy, payment will end on the effective date of termination.

(5) When ODJFS acts under instructions from the United States department of health and human services, payment ends on the date specified by that agency.

Replaces: 5101:3-3- 04.1

Effective: 01/10/2013
R.C. 119.032 review dates: 01/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.21
Prior Effective Dates: 3/18/88 (Emer.), 6/16/88, 1/1/95, 7/1/00, 7/1/03, 7/1/08

5160-3-05 Level of care definitions.

(A) This rule contains the definitions used in the process of making a determination of an individual's level of care. The definitions in this rule apply unless a term is otherwise defined in a specific rule.

(B) Definitions.

(1) "Active Treatment" means a continuous treatment program including aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services for individuals with mental retardation and/or other developmental disabilities that are directed toward the following:

(a) The acquisition of the behaviors necessary for the individual to function with as much self determination and independence as possible; and

(b) The prevention or deceleration of regression or loss of current optimal functional status.

(2) "Activity of daily living (ADL)" means a personal or self-care task that enables an individual to meet basic life needs. For purposes of this rule, the term "ADL" includes the following defined activities:

(a) "Bathing" means the ability of an individual to cleanse one's body by showering, tub, or sponge bath, or any other generally accepted method.

(b) "Dressing" means the ability of an individual to complete the activities necessary to dress oneself and includes the following two components:

(i) Putting on and taking off an item of clothing or prosthesis; and

(ii) Fastening and unfastening an item of clothing or prosthesis.

(c) "Eating" means the ability of an individual to feed oneself. Eating includes the processes of getting food into one's mouth, chewing, and swallowing, and/or the ability to use and self-manage a feeding tube.

(d) "Grooming" means the ability of an individual to care for one's appearance and includes the following three components:

(i) Oral hygiene;

(ii) Hair care; and

(iii) Nail care.

(e) "Mobility" means the ability of an individual to use fine and gross motor skills to reposition or move oneself from place to place and includes the following three components:

(i) "Bed mobility" means the ability of an individual to move to or from a lying position, turn from side to side, or otherwise position the body while in bed or alternative sleep furniture;

(ii) "Locomotion" means the ability of an individual to move between locations by ambulation or by other means; and

(iii) "Transfer" means the ability of an individual to move between surfaces, including but not limited to, to and from a bed, chair, wheelchair, or standing position.

(f) "Toileting" means the ability of an individual to complete the activities necessary to eliminate and dispose of bodily waste and includes the following four components:

(i) Using a commode, bedpan, or urinal;

(ii) Changing incontinence supplies or feminine hygiene products;

(iii) Cleansing self; and

(iv) Managing an ostomy or catheter.

(3) "Adverse level of care determination" means a determination that an individual does not meet the criteria for a specific level of care.

(4) "Alternative form" means a form that is used in place of and contains all of the data elements of, the JFS 03697, "Level of Care Assessment" (rev. 4/2003) to request a level of care determination from the Ohio department of job and family services (ODJFS) or its designee.

(5) "Assistance" means the hands-on provision of help in the initiation and/or completion of a task.

(6) "Authorized representative" has the same meaning as in rule 5101:1-37-01 of the Administrative Code.

(7) "CBDD" means a county board of developmental disabilities as established under Chapter 5126. of the Revised Code.

(8) "Current diagnoses" means a written medical determination by the individual's attending physician, whose scope of practice includes diagnosis, listing those diagnosed conditions that currently impact the individual's health and functional abilities.

(9) "Delayed face-to-face visit" means an in-person visit that occurs within a specified period of time after a desk review has been conducted that includes the elements of a long-term care consultation, in accordance with Chapter 173-43 of the Administrative Code, for the purposes of exploring home and community-based services (HCBS) options and making referrals to the individual as appropriate.

(10) "Desk review" means a level of care determination process that is not conducted in person.

(11) "Developmental delay" means that an individual age birth through five has not achieved developmental milestones as expected for the individual's chronological age as measured, documented, and determined by qualified professionals using generally accepted diagnostic instruments or procedures.

(12) "Face-to-face" means an in-person level of care assessment and determination process with the individual for the purposes of exploring nursing facility services or HCBS options and making referrals to the individual as appropriate, that is not conducted by a desk review only.

(13) "Habilitation" in accordance with 42 U.S.C. 1396n(c)(5) as in effect December 27, 2005, means services designed to assist individuals in acquiring, retaining, and improving the self-help, socialization, and adaptive skills necessary to reside successfully in home and community-based settings.

(14) "ICF-MR" means an intermediate care facility for persons with mental retardation.

(15) "ICF-MR-based level of care" means the levels of care as described in rules 5101:3-3-07, 5101:3-3-15.3, and 5101:3-3- 15.5 of the Administrative Code.

(16) "Individual" means a medicaid recipient or person with pending medicaid eligibility.

(17) "Instrumental activity of daily living (IADL)" means the ability of an individual to complete community living skills. For the purposes of this rule, the term "IADL" includes the following defined activities:

(a) "Community access " means the ability of an individual to use available community services and supports to meet one's needs and includes the following three components:

(i) "Accessing transportation" means the ability to get and use transportation.

(ii) "Handling finances" means the ability of an individual to manage one's money and does not include transportation. Handling finances includes all of the following:

(a) Knowing where money is;

(b) Knowing how to get money;

(c) Paying bills; and

(d) Knowing how to get and use benefits and services, including but not limited to:

(i) Health benefits and insurance;

(ii) Social benefits; and

(iii) Home utilities.

(iii) "Telephoning" means the ability to make and answer telephone calls or use technology to connect to community services and supports.

(b) "Environmental management" means the ability of an individual to maintain the living arrangement in a manner that ensures the health and safety of the individual and includes the following three components:

(i) "Heavy chores" means the ability to move heavy furniture and appliances for cleaning, turn mattresses, and wash windows and walls; and

(ii) "House cleaning" means the ability to make beds, clean the bathroom, sweep and mop floors, dust, clean and store dishes, pick up clutter, and take out trash;

(iii) "Yard work and/or maintenance" means the ability to care for the lawn, rake leaves, shovel snow, complete minor home repairs, and paint.

(c) "Meal preparation" means the ability of an individual to prepare or cook food for oneself.

(d) "Personal laundry" means the ability of an individual to wash and dry one's clothing and household items by machine or by hand.

(e) "Shopping" means the ability to obtain or purchase one's necessary items.Necessary items include, but are not limited to, groceries, clothing, and household items. Shopping does not include handling finances or accessing transportation.

(18) "Less than twenty-four hour support" means that an individual requires the presence of another person, or the presence of a remote monitoring device that does not require the individual to initiate a response, during a portion of a twenty-four hour period of time.

(19) "Level of care determination" means an assessment and evaluation by ODJFS or its designee of an individual's physical, mental, social, and emotional status, using the processes described in rules 5101:3-3-15, 5101:3-3-15.3, and 5101:3-3-15.5 of the Administrative Code, to compare the criteria for all of the possible levels of care as described in rules 5101:3-3-06 to 5101:3-3-08 of the Administrative Code, and make a decision about whether an individual meets the criteria for a level of care.

(20) "Level of care validation" means the verification process for ODJFS or its designee to review and enter an individual's current level of care in the electronic records of the individual that are maintained by ODJFS.

(21) "Long-term services and supports" means institutional or community-based medical, health, psycho-social, habilitative, rehabilitative, or personal care services that may be provided to medicaid-eligible individuals.

(22) "Major life area" has the same meaning as in rule 5101:3-3-07 of the Administrative Code.

(23) "Manifested" means a condition is diagnosed and interferes with the individual's ability to develop or maintain functioning in at least one major life area.

(24) "Medication administration" means the ability of an individual to prepare and self-administer all forms of over-the-counter and prescription medication.

(25) "Need" means the inability of an individual to complete a necessary and applicable task independently, safely, and consistently. An individual does not have a need when:

(a) The individual is not willing to complete a task or does not have the choice to complete a task.

(b) The task can be completed with the use of available assistive devices and accommodations.

(26) "Nursing facility (NF)" has the same meaning as in section 5111.20 of the Revised Code. A facility that has submitted an application packet for medicaid certification to ODJFS is considered to be in the process of obtaining its initial medicaid certification by the Ohio department of health and shall be treated as a NF for the purposes of this rule.

(27) "NF-based level of care" means the intermediate and skilled levels of care, as described in rule 5101:3-3-08 of the Administrative Code.

(28) "NF-based level of care program" means a NF, a home and community-based services medicaid waiver that requires a NF-based level of care, or other medicaid program that requires a NF-based level of care.

(29) "PASRR" means the preadmission screening and resident review requirements mandated by section 1919(e)(7) of the Social Security Act and implemented in accordance with rules 5101:3-3-14, 5101:3-3-15.1, 5101:3-3- 15.2 and 5122-21-03 and 5123:2-14-01 of the Administrative Code.

(30) "Physician" means a person licensed under Chapter 4731. of the Revised Code or licensed in another state as defined by applicable law, to practice medicine and surgery or osteopathic medicine and surgery.

(31) "Psychiatrist" means a physician licensed under Chapter 4731. of the Revised Code or licensed in another state as defined by applicable law, to practice psychiatry.

(32) "Psychologist" means, a person licensed in Ohio as a psychologist or school psychologist, or licensed in another state as a psychologist as defined by applicable law.

(33) The terms "psychologist," "the practice of psychology," "psychological procedures," "school psychologist," "practice of school psychology," "licensed psychologist," "licensed school psychologist," and "certificated school psychologist" have the same meanings as in section 4732.01 of the Revised Code.

(34) "Skilled nursing services" means specific tasks that must, in accordance with Chapter 4723. of the Revised Code, be provided by a licensed practical nurse (LPN) at the direction of a registered nurse or by a registered nurse directly.

(35) "Skilled rehabilitation services" means specific tasks that must, in accordance with Title 47 of the Revised Code, be provided directly by a licensed or other appropriately certified technical or professional health care personnel.

(36) "Sponsor" means an adult relative, friend, or guardian of an individual who has an interest in or responsibility for the individual's welfare.

(37) "Substantial functional limitation" means the inability of an individual to independently, adequately, safely, and consistently perform age-appropriate tasks as associated with the major life areas and as referenced in paragraph (B)(4) of this rule, without undue effort and within a reasonable period of time. An individual who has access to and is able to perform the tasks independently, adequately, safely, and consistently with the use of adaptive equipment or assistive devices is not considered to have a substantial functional limitation.

(38) "Supervision" means either of the following:

(a) Reminding an individual to perform or complete an activity; or

(b) Observing while an individual performs an activity to ensure the individual's health and safety.

(39) "Twenty-four hour support" means that an individual requires the continuous presence of another person throughout the course of the entire day and night during a twenty-four hour period of time.

(40) "Unstable medical condition" means clinical signs and symptoms are present in an individual and a physician has determined that:

(a) The individual's signs and symptoms are outside of the normal range for that individual;

(b) The individual's signs and symptoms require extensive monitoring and ongoing evaluation of the individual's status and care and there are supporting diagnostic or ancillary testing reports that justify the need for frequent monitoring or adjustment of the treatment regimen;

(c) Changes in the individual's medical condition are uncontrollable or unpredictable and may require immediate interventions; and

(d) A licensed health professional must provide ongoing assessments and evaluations of the individual that will result in adjustments to the treatment regimen as medically necessary. The adjustments to the treatment regimen must happen at least monthly, and the designated licensed health professional must document that the medical interventions are medically necessary.

Replaces: Part of 5101:3-3-05, 5101:3-3-06, 5101:3-3-07,5101:3-3-08, 5101:3-3-15

Effective: 03/17/2012
R.C. 119.032 review dates: 03/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.204 , 5111.205
Prior Effective Dates: 4/7/77, 10/14/77, 7/1/80, 11/10/83, 8/1/84, 1/17/92 (Emer.), 4/16/92, 9/24/93 (Emer.), 10/1/93 (Emer.), 12/24/93, 12/31/93, 11/5/01 (Emer.), 1/20/02, 7/1/08

5160-3-06 Criteria for the protective level of care.

(A) This rule describes the criteria for an individual to meet the protective level of care.

(B) The criteria for the protective level of care is met when:

(1) The individual's needs for long-term services and supports (LTSS), as defined in rule 5101:3-3-05 of the Administrative Code, are less than the criteria for the intermediate or skilled levels of care, as described in paragraphs (B)(4), (C), and (D)(4) of rule 5101:3-3-08 of the Administrative Code.

(2) The individual's LTSS needs are less than the criteria for the ICF-MR-based level of care, as defined in rule 5101:3-3-05 of the Administrative Code.

(3) The individual has a need for:

(a) Less than twenty-four hour support, as defined in rule 5101:3-3-05 of the Administrative Code, in order to prevent harm due to a cognitive impairment, as diagnosed by a physician or other licensed health professional acting within his or her applicable scope of practice, as defined by law; or

(b) Supervision, as defined in rule 5101:3-3-05 of the Administrative Code, of one activity of daily living (ADL), as defined in rule 5101:3-3-05 of the Administrative Code and as described in paragraph (C) of this rule, or supervision of medication administration, as defined in rule 5101:3-3-05 of the Administrative Code; and

(c) Assistance, as defined in rule 5101:3-3-05 of the Administrative Code, with three instrumental activities of daily living (IADL), as defined in rule 5101:3-3-05 of the Administrative Code and as described in paragraph (D) of this rule.

(C) For the purposes of meeting the criteria described in paragraph (B)(3) of this rule, an individual has a need in an ADL when:

(1) The individual requires supervision of mobility in at least one of the following three components:

(a) Bed mobility;

(b) Locomotion; or

(c) Transfer.

(2) The individual requires supervision of bathing.

(3) The individual requires supervision of grooming in all of the following three components:

(a) Oral hygiene;

(b) Hair care; and

(c) Nail care.

(4) The individual requires supervision of toileting in at least one of the following four components:

(a) Using a commode, bedpan, or urinal;

(b) Changing incontinence supplies or feminine hygiene products;

(c) Cleansing self; or

(d) Managing an ostomy or catheter.

(5) The individual requires supervision of dressing in at least one of the following two components:

(a) Putting on and taking off an item of clothing or prosthesis; or

(b) Fastening and unfastening an item of clothing or prosthesis.

(6) The individual requires supervision of eating.

(D) For the purposes of meeting the criteria described in paragraph (B)(3) of this rule, an individual has a need in an IADL when:

(1) The individual requires assistance with meal preparation.

(2) The individual requires assistance with environmental management in all of the following three components:

(a) Heavy chores;

(b) House cleaning; and

(c) Yard work and/or maintenance.

(3) The individual requires assistance with personal laundry.

(4) The individual requires assistance with community access in at least one of the following three components:

(a) Accessing transportation;

(b) Handling finances; or

(c) Telephoning.

(5) The individual requires assistance with shopping.

Replaces: Part of 5101:3-3-08

Effective: 03/19/2012
R.C. 119.032 review dates: 03/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.204
Prior Effective Dates: 9/24/93 (Emer.), 12/24/93, 7/1/08

5160-3-06.1 Institutions for mental diseases (IMDs).

(A) Section 1905 (a) of the Social Security Act provides that federal financial participation (FFP) is not available for any medical assistance for individuals who are in an institution for mental disease (IMD) unless the payments are for inpatient hospital or nursing facility (NF) services for individuals sixty-five years of age or older, or for inpatient psychiatric hospital services for individuals under age twenty-one, and in certain circumstances under age twenty-two. The purpose of this rule is to set forth the process by which the Ohio department of medicaid (ODM) shall identify nursing facilities (NFs) that are at risk of becoming IMDs, the preventive measures to be taken by ODM when such facilities have been identified, and the course of action to be taken if a NF is identified as an IMD.

(B) Definitions.

(1) "At risk facility". A NF is considered to be an at risk facility if it meets two or more of the IMD evaluation criteria set forth in paragraph (C)(2)(b) of this rule but has not been determined to meet the definition of IMD set forth in paragraph (B)(2) of this rule.

(2) "Institution for mental diseases (IMD)" means a hospital, nursing facility, or other institution of more than sixteen beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care and related services. A NF is considered to be an IMD if its overall character is that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. An intermediate care facility for the mentally retarded (ICF-MR) is not an IMD.

(3) "Mental diseases" means diseases listed as mental disorders in the "International Classification of Diseases, Tenth Revision, Clinical Modification," or the most recent edition, with the exception of mental retardation, senility, and organic brain syndrome. This publication is available on the internet via the websitehttp://www.cdc.gov/nchs/icd/icd10cm.htm.

(4) "Potentially at risk of becoming an IMD". A NF is considered to be potentially at risk of becoming an IMD if any one of the following applies:

(a) The NF is licensed as a mental nursing home as defined in rule 3701-17-01 of the Administrative Code;

(b) The NF was identified as an at risk facility during a prior IMD review; or

(c) Forty-five per cent or more of the NF's residents have been determined to need specialized services for serious mental illness by the Ohio department of mental health and addiction services (ODMHAS) in accordance with rules 5160-3- 15.1, 5160-3- 51.2, and 5122-21-03 of the Administrative Code.

(C) Identification of at risk facilities and IMDs.

(1) ODM shall identify and maintain a list of NFs that are potentially at risk of becoming IMDs.

(2) IMD reviews shall be conducted for any potentially at risk facility on the list.

(a) IMD reviews shall be scheduled as follows:

(i) ODM shall schedule and complete an initial on-site IMD review of any NF that is newly identified as meeting the criteria set forth in paragraphs (B)(4)(a) and/or (B)(4)(c) of this rule. Initial reviews shall be completed within sixty calendar days following the identification of the NF's potentially at risk status;

(ii) ODM shall conduct annual on-site IMD reviews in each potentially at risk facility for at least two consecutive years after it is identified as potentially at risk of becoming an IMD.

(b) IMD review criteria. The following criteria shall be used to evaluate the overall character of a NF:

(i) Whether the NF is licensed as a psychiatric facility. For purposes of this rule, this includes licensure as a mental nursing home in accordance with rule 3701-17-01 of the Administrative Code;

(ii) Whether the NF is accredited as a psychiatric facility by the "Joint Commission," which accredits and certifies health care organizations and programs in the United States;

(iii) Whether the NF is under the jurisdiction of the ODMHAS;

(iv) Whether the NF specializes in providing psychiatric and/or psychological care and treatment, as evidenced by any of the following indicators:

(a) Fifty per cent or more of individuals residing in the NF have medical records indicating that they are receiving psychiatric/psychological care and treatment;

(b) Fifty per cent or more of the NF's staff have specialized psychiatric/psychological training; or

(c) Fifty per cent or more of individuals residing in the NF are receiving psychopharmacological drugs; and

(v) Whether the current need for institutionalization for more than fifty per cent of all the individuals residing in the NF results from mental diseases. In determining whether this criterion is met, the reviewer must consider whether more than fifty per cent of individuals residing in the NF have serious mental illness (as defined in rule 5160-3-15 of the Administrative Code) and have been determined by ODMHAS to need specialized services for serious mental illness in accordance with rule 5160-3- 15.1 or 5160-3- 15.2, and rule 5122-21-03 of the Administrative Code.

(c) IMD review results. At the conclusion of each IMD review, ODM shall make one of the following determinations:

(i) The NF is not at risk of becoming an IMD;

(ii) The NF is an at risk facility as defined in paragraph (B)(1) of this rule; or

(iii) The facility is determined to be an IMD.

(D) ODM action pursuant to IMD review results. Upon completion of the IMD review, ODM shall proceed with the follow-up activities corresponding to the determination that was made for the NF:

(1) For NFs determined not to be at risk of becoming an IMD:

(a) Any NF that is determined not to meet the criteria for potential risk shall be notified and removed from the list of facilities that are potentially at risk of becoming an IMD.

(b) Any NF determined to be potentially at risk of becoming an IMD but that does not meet at least two of the IMD review criteria set forth in paragraph (C)(2)(b) of this rule shall be notified of its status as a potentially at risk facility and that it shall continue to be subject to annual IMD reviews, and retained on the list of facilities that are potentially at risk of becoming an IMD.

(2) NFs determined to be at risk of becoming an IMD shall be notified of the determination, offered the opportunity to receive technical assistance to prevent them from becoming IMDs, and shall be monitored closely by ODM following the at risk determination. Such monitoring may include the performance of additional, unannounced, on-site IMD reviews by ODM.

(3) For NFs determined to be an IMD:

(a) The NF shall be notified by certified mail of the determination, that eligibility to receive medicaid vendor payment shall be terminated with respect to all individuals residing in that NF who are under age sixty-five, and that it has ten working days from the date the notice was mailed to exercise its appeal rights pursuant to paragraph (B) of rule 5160-1-57 of the Administrative Code;

(b) If the facility requests a reconsideration pursuant to paragraph (B) of rule 5160-1-57 of the Administrative Code, eligibility to receive vendor payment will continue until the issuance of a final decision by ODM.

(c) On the eleventh day following the date the IMD determination notice was mailed to the NF, or upon issuance of a final decision by ODM, if the IMD determination is upheld on appeal, ODM shall notify the county department of job and family services (CDJFS) in writing, to initiate the process for termination of the vendor payment and a redetermination of the residents' continued eligibility for medicaid and to provide notice of all applicable appeal rights to all affected residents of that IMD in accordance with Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.

(E) A NF which has been determined to be an IMD may, following a period of not less than six months, submit a written request that ODM conduct a redetermination survey when changes have been made in its overall character such that the administrator of the facility believes it would no longer qualify as an IMD. ODM shall respond to such requests by conducting a redetermination survey within sixty days of the receipt of the request.

(1) If the redetermination survey finds that the NF no longer meets the definition of an IMD set forth in paragraph (B)(2) of this rule, ODM shall:

(a) Follow the procedures set forth in paragraph (D)(1) or (D)(2) of this rule; and

(b) Notify the CDJFS in writing, of the effective date of the determination that the facility is not an IMD, to initiate vendor payment, regardless of the age of the individual and in accordance with rule 5160-3-15 of the Administrative Code, on behalf of medicaid eligible individuals seeking medicaid payment of their stay in that NF.

(2) If the redetermination survey finds that the NF continues to be an IMD, the NF shall be notified by certified mail of the determination, the basis for the determination, that it has ten working days from the date the notice was mailed to exercise its appeal rights pursuant to paragraph (B) of rule 5160-1-57 of the Administrative Code, and that if the NF does not exercise its appeal rights within that time it may not request another reconsideration survey for at least six months from the date of the determination.

Effective: 10/03/2014
Five Year Review (FYR) Dates: 07/17/2014 and 10/03/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.06
Prior Effective Dates: 6/15/88 (Emer.), 8/29/88, 9/1/94, 7/1/08

5160-3-07 Intermediate care for individuals with mental retardation and developmental disabilities.

(A) This rule sets forth the criteria used to determine whether an individual who is seeking medicaid payment for long-term care services, as defined in rule 5101:3-3-15 of the Administrative Code, needs services at the level of intermediate care facility services for the mentally retarded, as defined in rule 5101:3-3-15.3 of the Administrative Code. The criteria set forth in this rule must be used when determining level of care for individuals seeking medicaid coverage of either home and community-based services(HCBS) waivers or facility-based institutional long term care services.

(B) Definitions.

(1) "Active Treatment"

(a) "Active treatment" means the continuous, aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services described in 42 CFR 483, dated October 1, 2007 that is directed toward:

(i) The acquisition of the behaviors necessary for the individual to function with as much self determination and independence as possible; and

(ii) The prevention or deceleration of regression or loss of current optimal functional status.

(b) Active treatment does not include services to maintain generally independent individuals who are able to function with little supervision or in the absence of a continuous active treatment program.

(2) "Developmental delay" means that an individual has not achieved developmental milestones as expected for the individual's chronological age as measured, documented, and determined by qualified professionals using generally accepted diagnostic instruments and/or procedures.

(3) "Habilitation", as defined in section 5126.01 of the Revised Code, means the process by which the staff of a facility or agency assists an individual with mental retardation or other developmental disabilities in acquiring and maintaining those life skills that enable the individual to cope more effectively with the demands of the individual's own person and environment, and in raising the level of the individual's personal, physical, mental, social, and vocational efficiency.

(4) "HCBS", as defined in section 5126.01 of the Revised Code means medicaid-funded home and community based services as an alternative to placement in an intermediate care facility for mental retardation provided under a medicaid component that the department of mental retardation and developmental disabilities administers pursuant to section 5111.871 of the Revised Code.

(5) "Major life area" refers to categories that are related to the age appropriate performance of life activities and includes the following:

(a) "Capacity for independent living" means:

(i) For individuals age sixteen years and older, the ability to safely carry out all of the following tasks:

(a) Purchase groceries, clothing and household items; and

(b) Plan and prepare nutritious meals; and

(c) Respond to emergencies; and

(d) Clean house, make beds, sweep and mop floors, dust, wash dishes, pick up clutter, take out trash; and

(e) Wash and dry clothing; and

(f) Make and answer telephone calls; and

(g) Use public or private transportation to access the community; or

(ii) For individuals age nine through fifteen years, the ability to safely carry out all of the following tasks:

(a) Prepare a snack; and

(b) Respond to emergencies; and

(c) Participate in household chores; and

(d) Use neighborhood resources such as playground, corner store, neighbors' houses; or, for individuals age twelve years and older, use public transportation; and

(e) For ages nine through eleven years, stay alone for at least two hours with a responsible adult in another part of the house; and

(f) For ages twelve through fifteen years, stay alone for at least two hours; or

(iii) For individuals age six through eight years, the ability to safely carry out all of the following tasks:

(a) Prepare a simple snack; and

(b) Respond to emergencies; and

(c) Participate in household chores; and

(d) Use neighborhood resources, with supervision appropriate to age and as appropriate to community standards, such as playground, corner store, or neighbors' houses; and

(e) Stay alone for at least two hours with a responsible adult in another part of the house within visual or hearing distance.

(b) "Communication" means the age appropriate ability to express needs and wants in a manner that is understandable to people who do not know the individual, using spoken, written, signed, electronic or mechanical means and to understand such communication as appropriate to age.

(c) "Economic self-sufficiency" means the ability of individuals age sixteen years and older to do at least two of the following:

(i) Obtain and engage in community employment;

(ii) Pay bills;

(iii) Manage money;

(iv) Access insurance and/or public benefits.

(d) "Learning" means the cognitive ability to acquire, retain and apply new information, skills and attitudes as appropriate to age.

(e) "Mobility" means the ability to do all of the following with or without the use of one or more assistive devices:

(i) Transfer between surfaces (including but not limited to; to/from bed, chair, wheelchair, standing position, in and out of car, up and down steps or curbs etc); and

(ii) Move between locations by ambulation or other means both at home and in the community.

(f) "Personal care" means

(i) For individuals age sixteen years and older, the ability to do all of the following with or without the use of one or more assistive devices:

(a) Bathe, including cleansing one's body by showering, tub or sponge bath, or any other generally accepted method; and

(b) Perform the tasks associated with oral hygiene, hair and nail care; and

(c) Perform the tasks associated with toileting, which includes appropriate elimination, disposal of bodily waste, and adequate hygiene related to toileting.

(d) Dress self, including putting on and taking off all items of clothing, including any necessary prostheses; and

(e) Feed self, including the processes of getting food into one's mouth, chewing and swallowing, and/or the ability to use and manage a feeding tube; and

(f) Self-administer medications as defined in Chapter 47. of the Revised Code.

(ii) For individuals age six through fifteen years, the ability to do all of the following with or without the use of one or more assistive devices:

(a) Bathe, including cleansing one's body by showering, tub or sponge bath, or any other generally accepted method; and

(b) Perform the tasks associated with oral hygiene and hair care; and

(c) Perform the tasks associated with toileting, which includes appropriate elimination, disposal of bodily wastes, and adequate and hygiene related to toileting.

(d) Dress self, including putting on and taking off all items of clothing, including any necessary prostheses; and

(e) Feed self, including the processes of getting food into one's mouth, chewing, and swallowing.

(g) "Self-direction" means:

(i) For individuals age sixteen years and older, the ability to do all of the following:

(a) Foresee the outcome of one's actions; and

(b) Make informed choices that are unlikely to result in harm to self or others; and

(c) Initiate appropriate activities; and

(d) Exercise self-control in daily life; or,

(ii) For individuals age nine through fifteen years, the ability to do all of the following:

(a) Foresee the outcome of one's actions, understand cause and effect, and change future decisions based on past consequences; and

(b) Make informed choices that are unlikely to result in harm to self or others, demonstrate good judgement when asking for help when needed for physical, emotional and practical needs; and

(c) Initiate appropriate activities, show adequate social skills for establishing and maintaining relationships; and

(d) Exercise self-control in daily life, occupy self without difficulty, follow basic rules; and

(iii) For individuals ages six through eight years, the ability to do all of the following:

(a) Foresee the outcome of one's actions, understand basic cause and effect, and change future decisions based on past consequences; and

(b) Make informed choices that are unlikely to result in harm to self or others, demonstrate judgement when asking for help when needed for physical, emotional and practical needs; and

(c) Initiate appropriate activities, show adequate social skills for relationships such as turn taking and sharing; and

(d) Exercise self-control in daily life, can occupy self for short periods of time without difficulty, and follow basic rules.

(6) "Manifested" means a condition was diagnosed and has interfered with the individual's ability to develop and/or maintain functioning in at least one major life area, as referenced in paragraph (B)(5) of this rule.

(7) "Substantial functional limitation" means the inability to independently, adequately, safely, and consistently perform age appropriate tasks as associated with the major life areas, as referenced in paragraph (B)(5) of this rule, without undue effort and within a reasonable period of time. An individual who has access to and is able to perform the tasks independently, adequately, safely, and consistently with the use of adaptive equipment or assistive devices is not considered to have a substantial functional limitation.

(C) An individual that is age six years or older shall be determined to require an ICF-MR level of care if all of the following criteria are met:

(1) The individual meets the minimum criteria for a protective level of care set forth in paragraph (C)(2) of rule 5101:3-3-08 of the Administrative Code; and

(2) The individual has at least one diagnosed condition other than mental illness; and

(3) The condition(s) referenced in paragraph (C)(2) of this rule was manifested before the individual's twenty-second birthday; and

(4) The condition(s) referenced in paragraph (C)(2) of this rule is likely to continue indefinitely; and

(5) The condition(s) referenced in paragraph (C)(2) of this rule currently results in:

(a) Substantial functional limitations in three or more of the following major life areas for individuals age six through fifteen:

(i) Capacity for independent living;

(ii) Communication;

(iii) Learning;

(iv) Mobility;

(v) Personal care;

(vi) Self-direction; or

(b) Substantial functional limitations in three or more of the following major life areas for individuals age sixteen and older:

(i) Capacity for independent living;

(ii) Communication;

(iii) Economic self-sufficiency;

(iv) Learning;

(v) Mobility;

(vi) Personal care;

(vii) Self-direction; and

(6) The individual would benefit from services and supports designed and coordinated specifically to promote the individual's acquisition of skills and to decrease or prevent regression in the performance of tasks related to the major life areas, as referenced in paragraph (B)(5) of this rule, where significant functional limitations were identified. These services and supports are to be provided in one of the following settings:

(a) An intermediate care facility for the mentally retarded (ICF-MR) where active treatment is provided, as defined in paragraph (B)(1) of this rule; or

(b) A home and community based services waiver where habilitation services are provided, as defined in paragraph (B)(3) of this rule.

(7) The individual, parent of a minor child, or legal guardian agrees to the individual's active participation in an individualized plan of services and supports.

(D) An individual birth through five years of age shall be determined to require an ICF-MR level of care if all of the following criteria are met:

(1) The individual meets the minimum criteria for a protective level of care set forth in paragraph (C)(2) of rule 5101:3-3-08 of the Administrative Code; and

(2) The individual has demonstrated at least three developmental delays, as defined in paragraph (B)(2) of this rule, in the following areas:

(a) Adaptive behavior;

(b) Physical development or maturation, fine and gross motor skills, growth;

(c) Cognition;

(d) Communication;

(e) Social or emotional development;

(f) Sensory development; and

(3) The individual would benefit from services and supports designed and coordinated specifically to promote the individual's acquisition of skills and to decrease or prevent regression in the performance of those areas where delays are indicated. These services and supports are to be provided in one of the following settings:

(a) An intermediate care facility for the mentally retarded where active treatment is provided, as defined in paragraph (B)(1) of this rule; or

(b) A home and community based services waiver where habilitation services are provided, as defined in paragraph (B)(3) of this rule.

(4) The parent or legal guardian agrees to the individual's active participation in an individualized plan of services and supports.

Effective: 07/01/2008
R.C. 119.032 review dates: 04/07/2008 and 07/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.02
Prior Effective Dates: 4/7/77, 10/14/77, 7/1/80, 11/5/01 (Emer.), 1/20/02

5160-3-08 Criteria for nursing facility-based level of care.

(A) This rule describes the criteria for an individual to meet the nursing facility (NF)-based level of care. The NF-based level of care includes the intermediate and skilled levels of care. An individual is determined to meet the NF-based level of care when the individual meets the criteria as described in paragraphs (B) to (D) of this rule.

(B) The criteria for the intermediate level of care is met when:

(1) The individual's needs for long-term services and supports (LTSS), as defined in rule 5101:3-3-05 of the Administrative Code, exceed the criteria for the protective level of care, as described in paragraph (B)(3) of rule 5101:3-3-06 of the Administrative Code.

(2) The individual's LTSS needs are less than the criteria for the skilled level of care, as described in paragraph (D)(4) of this rule.

(3) The individual's LTSS needs do not meet the criteria for the ICF-MR-based level of care, as defined in rule 5101:3-3-05 of the Administrative Code.

(4) The individual has a need for a minimum of one of the following:

(a) Assistance, as defined in rule 5101:3-3-05 of the Administrative Code, with the completion of a minimum of two activities of daily living (ADL), as defined in rule 5101:3-3-05 of the Administrative Code and as described in paragraph (C) of this rule;

(b) Assistance with the completion of a minimum of one ADL as described in paragraph (C) of this rule, and assistance with medication administration, as defined in rule 5101:3-3-05 of the Administrative Code;

(c) A minimum of one skilled nursing service or skilled rehabilitation service, as defined in rule 5101:3-3-05 of the Administrative Code; or

(d) Twenty-four hour support, as defined in rule 5101:3-3-05 of the Administrative Code, in order to prevent harm due to a cognitive impairment, as diagnosed by a physician or other licensed health professional acting within his or her applicable scope of practice, as defined by law.

(C) For the purposes of meeting the criteria described in paragraph (B)(4) of this rule, an individual has a need in an ADL when:

(1) The individual requires assistance with mobility in at least one of the following three components:

(a) Bed mobility;

(b) Locomotion; or

(c) Transfer.

(2) The individual requires assistance with bathing.

(3) The individual requires assistance with grooming in all of the following three components:

(a) Oral hygiene;

(b) Hair care; and

(c) Nail care.

(4) The individual requires assistance with toileting in at least one of the following four components:

(a) Using a commode, bedpan, or urinal;

(b) Changing incontinence supplies or feminine hygiene products;

(c) Cleansing self; or

(d) Managing an ostomy or catheter.

(5) The individual requires assistance with dressing in at least one of the following two components:

(a) Putting on and taking off an item of clothing or prosthesis; or

(b) Fastening and unfastening an item of clothing or prosthesis.

(6) The individual requires assistance with eating.

(D) The criteria for the skilled level of care is met when:

(1) The individual's LTSS needs exceed the criteria for the protective level of care, as described in paragraph (B)(3) of rule 5101:3-3-06 of the Administrative Code.

(2) The individual's LTSS needs exceed the criteria for the intermediate level of care as described in paragraph (B)(4) of this rule.

(3) The individual's LTSS needs exceed the criteria for the ICF-MR-based level of care.

(4) The individual requires a minimum of one of the following:

(a) One skilled nursing service within the day on no less than seven days per week; or

(b) One skilled rehabilitation service within the day on no less than five days per week.

(5) The individual has an unstable medical condition, as defined in rule 5101:3-3-05 of the Administrative Code.

(E) When an individual meets the criteria for a skilled level of care, as described in paragraph (D) of this rule, the individual may request placement in an intermediate care facility for persons with mental retardation (ICF-MR) that provides services to individuals who have a skilled level of care. When an individual with a skilled level of care requests placement in an ICF-MR, the following requirements apply:

(1) The individual may be determined to meet the criteria for the ICF-MR-based level of care; and

(2) The ICF-MR must provide written certification that the services provided in the facility are appropriate to meet the needs of an individual who meets the criteria for a skilled level of care.

Replaces: Part of 5101:3-3-05, 5101:3-3-06

Effective: 03/19/2012
R.C. 119.032 review dates: 03/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.204
Prior Effective Dates: 7/1/80, 11/10/83, 10/1/93 (Emer.), 12/31/93, 7/1/08

5160-3-14 Process and timeframes for a level of care determination for nursing facility-based level of care programs.

(A) This rule describes the processes and timeframes for a level of care determination, as defined in rule 5101:3-3-05 of the Administrative Code, for a nursing facility (NF)-based level of care program, as defined in rule 5101:3-3-05 of the Administrative Code.

(1) The processes described in this rule shall not be used for a determination for an ICF-MR-based level of care, as defined in rule 5101:3-3-05 of the Administrative Code.

(2) A level of care determination may occur face-to-face or by a desk review, as defined in rule 5101:3-3-05 of the Administrative Code, and is one component of medicaid eligibility in order to:

(a) Authorize medicaid payment to a NF; or

(b) Approve medicaid payment of a NF-based home and community-based services (HCBS) waiver or other NF-based level of care program.

(3) An individual who is seeking a NF admission is subject to both a preadmission screening and resident review (PASRR) process, as described in rules 5101:3-3-14, 5101:3-3-15.1, 5101:3-3- 15.2, 5122-21-03, and 5123:2-14-01 of the Administrative Code, and a level of care determination process.

(a) The preadmission screening process must be completed before a level of care determination or a level of care validation can be issued.

(b) In order for the Ohio department of job and family services (ODJFS) to authorize payment to a NF, the individual must have received a non-adverse PASRR determination and subsequent NF-based level of care determination.

(i) ODJFS may authorize payment to the NF effective on the date of the PASRR determination.

(ii) The level of care effective date cannot precede the date that the PASRR requirements were met.

(iii) If a NF receives medicaid payment from ODJFS for an individual who does not have a NF-based level of care, the NF is subject to the claim adjustment for overpayments process described in rule 5101:3-1-19 of the Administrative Code.

(B) Level of care request.

(1) In order for ODJFS or its designee (hereafter referred to as ODJFS) to make a level of care determination, ODJFS must receive a complete level of care request. A level of care request is considered complete when all necessary data elements are included and completed on the JFS 03697, "Level of Care Assessment" (rev. 4/2003) or alternative form, as defined in rule 5101:3-3-05 of the Administrative Code, and any necessary supporting documentation is submitted with the JFS 03697 or alternative form, as described in paragraphs (B)(2) to (B)(4) of this rule.

(2) Necessary data elements on the JFS 03697 or alternative form:

(a) Individual's legal name;

(b) Individual's medicaid case number, or a pending medicaid case number;

(c) Date of original admission to the facility, if applicable;

(d) Individual's current address, including county of residence;

(e) Individual's current diagnoses;

(f) Date of onset for each diagnosis, if available;

(g) Individual's medications, treatments, and required medical services;

(h) A description of the individual's activities of daily living and instrumental activities of daily living;

(i) A description of the individual's current mental and behavioral status; and

(j) Type of service setting requested.

(3) Physician certification on the JFS 03697 or alternative form.

(a) A physician certification means a signature from a physician, as defined in rule 5101:3-3-05 of the Administrative Code, and date on the JFS 03697 or alternative form.

(b) A physician certification must be obtained within thirty calendar days of submission of the JFS 03697 or alternative form.

(c) Exceptions to the physician certification:

(i) When an individual resides in the community and ODJFS determines that the individual's health and welfare is at risk and that it is not possible for the submitter of the JFS 03697 or alternative form to obtain a physician signature and date at the time of the submission of the JFS 03697 or alternative form, a verbal physician certification is acceptable.

(ii) ODJFS must obtain a physician certification within thirty days of the verbal physician certification.

(4) Necessary supporting documentation with the JFS 03697 or alternative form when the individual is subject to a preadmission screening process:

(a) A copy of the JFS 03622, "Preadmission Screening/Resident Review (PAS/RR) Identification Screen" (rev. 11/2010) and JFS 07000, "Hospital Exemption from Preadmission Screening Notification" (rev. 11/2010), as applicable, in accordance with rules 5101:3-3-15.1 and 5101:3-3-15.2 of the Administrative Code; and

(b) Any preadmission screening results and assessment forms.

(C) Process when ODJFS receives a complete level of care request.

(1) When ODJFS determines that a level of care request is complete, ODJFS shall:

(a) Issue a level of care determination.

(b) Inform the individual, and/or the sponsor and the authorized representative, as applicable, about the individual's PASRR results.

(c) Notify the individual, and/or the sponsor and the authorized representative, as applicable, as defined in rule 5101:3-3-05 of the Administrative Code, of the level of care determination.

(d) When there is an adverse level of care determination, inform the individual, the sponsor, and the authorized representative, as applicable, about the individual's hearing rights in accordance with division 5101:6 of the Administrative Code.

(2) In accordance with rules 5101:1-38-01 and 5101:1-39-23 of the Administrative Code, the county department of job and family services (CDJFS) shall determine medicaid eligibility and issue proper notice and hearing rights to the individual.

(D) Process when ODJFS receives an incomplete level of care request.

(1) When ODJFS determines that a level of care request is not complete, ODJFS shall:

(a) Notify the submitter that a level of care determination cannot be issued due to an incomplete JFS 03697 or alternative form.

(b) Specify the necessary information the submitter must provide on or with the JFS 03697 or alternative form.

(c) Notify the submitter that the level of care request will be denied if the submitter does not submit the necessary information to ODJFS within fourteen calendar days.

(i) When the submitter provides a complete level of care request to ODJFS within the fourteen calendar day timeframe, ODJFS shall perform the steps described in paragraph (C) of this rule.

(ii) When the submitter does not provide a complete level of care request to ODJFS within the fourteen calendar day timeframe, ODJFS may deny the level of care request and document the denial in the individual's electronic record maintained by ODJFS.

(2) In accordance with rules 5101:1-38-01 and 5101:1-39-23 of the Administrative Code, the CDJFS shall determine medicaid eligibility and issue proper notice and hearing rights to the individual.

(E) Desk review level of care determination.

(1) A desk review level of care determination is required within one business day from the date of receipt of a complete level of care request when:

(a) ODJFS determines that an individual is seeking admission or re-admission to a NF from an acute care hospital or hospital emergency room.

(b) A CDJFS requests a level of care determination for an individual who is receiving adult protective services, as defined in rule 5101:2-20-01 of the Administrative Code, and the CDJFS submits a JFS 03697 or alternative form at the time of the level of care request.

(2) A desk review level of care determination is required within five calendar days from the date of receipt of a complete level of care request when:

(a) ODJFS determines that an individual who resides in a NF is requesting to change from a non-medicaid payor to medicaid payment for the individual's continued NF stay.

(b) ODJFS determines that an individual who resides in a NF is requesting to change from medicaid managed care to medicaid fee-for-service as payment for the individual's continued NF stay.

(c) ODJFS determines that an individual is transferring from one NF to another NF.

(F) Face-to-face level of care determination.

(1) A face-to-face level of care determination is required within ten calendar days from the date of receipt of a complete level of care request when:

(a) An individual or the authorized representative of an individual requests a face-to-face level of care determination.

(b) ODJFS makes an adverse level of care determination, as defined in rule 5101:3-3-05 of the Administrative Code, during a desk review level of care determination.

(c) ODJFS determines that the information needed to make a level of care determination through a desk review is inconsistent.

(d) An individual resides in the community and ODJFS verifies that the individual does not have a current NF-based level of care.

(e) ODJFS determines that an individual has a pending disenrollment from a NF-based HCBS waiver due to the individual no longer having a NF-based level of care.

(2) A face-to-face level of care determination is required within two business days from the date of a level of care request from a CDJFS for an individual who is receiving adult protective services when the CDJFS does not submit a JFS 03697 or alternative form at the time of the level of care request.

(G) Delayed face-to-face visit.

(1) A delayed face-to-face visit, as defined in rule 5101:3-3-05 of the Administrative Code, is required within ninety calendar days after ODJFS conducts a desk review level of care determination for an individual as described in paragraphs (E)(1)(a), (E)(1)(b), and (E)(2)(a) of this rule.

(2) The following are exceptions to the delayed face-to-face visit:

(a) An individual as described in paragraphs (E)(2)(b) and (E)(2)(c) of this rule.

(b) An individual who declines a delayed face-to-face visit.

(c) An individual who has had a long-term care consultation, in accordance with Chapter 173-43 of the Administrative Code, since the individual's NF admission.

(d) An individual who has had an in-person resident review, in accordance with Chapter 5101:3-3 of the Administrative Code, since the individual's NF admission.

(e) An individual who is receiving care under a medicaid care management system that utilizes a care management, case management, or care coordination model, including but not limited to case management services provided through an HCBS waiver.

(H) Level of care validation.

ODJFS may conduct a level of care validation, as defined in rule 5101:3-3-05 of the Administrative Code, in lieu of a face-to-face level of care determination within one business day from the date of a level of care request for:

(1) An individual who is enrolled on a NF-based HCBS waiver and is seeking admission to a NF.

(2) An individual who is a NF resident and is seeking readmission to the same NF after a hospitalization.

Replaces: 5101:3-3-15

Effective: 03/19/2012
R.C. 119.032 review dates: 03/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.204 , 5111.205
Prior Effective Dates: 4/7/77, 10/14/77, 7/1/80, 8/1/84, 1/17/92 (Emer.), 4/16/92, 10/1/93 (Emer.), 12/31/93, 7/1/08

5160-3-15 Preadmission screening (PAS) and resident review (RR) definitions.

(A) The purpose of this rule is to set forth the definitions for terms contained in rules 5101:3-3-15.1, 5101:3-3-15.2, 5122-21-03 and 5123:2-14-01 of the Administrative Code.

(B) Definitions:

(1) 'Active treatment' means a continuous treatment program including aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services for individuals with mental retardation and/or other developmental disabilities that are directed toward the following:

(a) The acquisition of the behaviors necessary for the client to function with as much self-determination and independence as possible; and

(b) The prevention, deceleration, regression or loss of current optimal functional status.

(2) 'Adverse determination' means a determination made in accordance with rules 5101:3-3-15.1, 5101:3-3-15.2, 5122-21-03 and 5123:2-14-01 of the Administrative Code, that an individual does not require the level of services provided by a nursing facility(NF). A determination that an individual does not require NF services shall meet both of the following conditions:

(a) A face-to-face assessment of the individual, and a review of the medical records accurately reflecting the individual's current condition, is performed by one of the following professionals within the scope of his/her practice.

(i) Medical doctor or doctor of osteopathic medicine;

(ii) Registered nurse (RN);

(iii) Master of science of nursing;

(iv) Clinical nurse specialist;

(v) Certified Nurse practitioner;

(vi) Licensed social worker, under supervision of a licensed independent social worker (LISW);

(vii) Licensed independent social worker;

(viii) Professional counselor, under supervision of a licensed professional clinical counselor (PCC);

(ix) Professional clinical counselor;

(x) Psychologist;

(b) Authorized personnel from the Ohio department of mental health (ODMH) and/or Ohio department of developmental disabilities (DODD), other than the personnel identified in paragraph (B)(2)(a) of this rule who have conducted the face-to-face assessment, have reviewed the assessment and made the final determination regarding the need for NF services and specialized services.

(3) 'Categorical determination' means a preadmission screening mental retardation developmental disabilities (PAS-MRDD) or preadmission screening serious mental illness (PAS-SMI) determination which may be made for an individual with MRDD and/or serious mental illness (SMI) without first completing a full PAS-MRDD and/or PAS-SMI evaluation when the individual's circumstances fall within one of the following two categories:

(a) The individual requires an 'emergency NF stay', as defined in paragraph (B)(7) of this rule;

(b) The individual is seeking admission to a NF for a 'respite NF stay' as defined in paragraph (B)(27) of this rule.

(4) 'Convalescent' exemption has the same meaning as hospital exemption defined in paragraph (B)(10) of this rule.

(5) 'Current diagnoses' means a written medical determination by the individual's attending physician, whose scope of practice includes diagnosis, listing those diagnosed conditions which currently impact the individual's health and functional abilities. To be considered current, the written documentation of the diagnoses must reflect the diagnoses was assigned by the individuals attending physician within one hundred eighty calendar days of submission for the PAS review certifying that the listed diagnoses are an accurate reflection of the individual's current condition;

(a) 'Primary diagnosis' means the diagnosis identified as the primary diagnosis by the physician, whose scope of practice includes diagnosis. If two or more diagnoses have such indications, none of them can be considered to be the primary diagnosis for the purposes of this rule.

(b) 'Secondary diagnosis' means any diagnoses other than a primary diagnosis as defined in paragraph (B)(5)(a) of this rule.

(6) 'Dementia.' An individual is considered to have dementia if he or she meets either of the following criteria:

(a) The individual has a primary diagnosis of a dementia, including alzheimer's disease or a related disorder, as described in the 'diagnostic and statistical manual of mental disorders,' fourth edition, text revision (DSM-IV-TR); or

(b) The individual has a secondary diagnosis of a dementia, including alzheimer's disease or a related disorder, (as described in the DSM-IV-TR), and a primary diagnosis which is not a major mental disorder specified in paragraph (B)(32)(a) of this rule.

(7) 'Emergency NF stay' means the individual is being admitted to a nursing facility pending further assessment for a period not to exceed seven days when the placement in the NF is necessary to avoid serious risk to the individual of immediate harm or death.

(8) 'Guardian' has the same meaning as in section 2111.01 of the Revised Code.

(9) Hospital (convalescent) exemption means an exemption from preadmission screening (PAS) for a new admission, as defined in paragraphs (B)(17)(a) to (B)(17)(d) of this rule, to a NF that meets the following criteria:

(a) The individual is to be admitted or enrolled directly from an Ohio hospital after receiving acute inpatient care at that hospital or is an Ohio resident being admitted or enrolled directly from an out-of-state hospital after receiving acute inpatient care at the hospital; and

(b) The individual requires the level of services provided by a NF for the condition which was treated in the hospital; and

(c) The individual's attending physician has provided written certification, signed and dated no later than the date of discharge from the hospital, stating that the individual is likely to require the level of services provided by a NF for less than thirty days.

(10) 'ICF/MR' means intermediate care facility for the mentally retarded. An ICF/MR is a long-term care facility certified to provide ICF/MR services, as defined in 42 C.F.R. 440.150 , dated October 1, 2008 to individuals with mental retardation or related conditions requiring active treatment.

(11) 'Indications of mental retardation and/or other developmental disabilities (MRDD)'. An individual shall be considered to have indications of mental retardation and/or other developmental disabilities if the individual meets the criteria specified in paragraph (B)(16) of this rule or the individual receives services from a county board of developmental disabilities (CBDD).

(12) 'Indications of serious mental illness (SMI).' An individual shall be considered to have indications of serious mental illness if the individual meets at least two of the three criteria specified in paragraph (B)(32) of this rule or, due to a mental impairment, receives supplemental security income authorized under Title XVI of the Social Security Act, as amended, or social security disability insurance authorized under Title II of the Social Security Act.

(13) 'Individual' for the purposes of this rule, means a person regardless of payment source, who is seeking admission, readmission or transfer to a NF, or who resides in a NF or facility in the process of becoming certified as a NF.

(14) 'Long-term resident' means an individual who has continuously resided in a NF or a consecutive series of NF's and/or medicare skilled nursing facilities for at least thirty months prior to the first resident review (RR) determination in which the individual was found not to require the level of services provided by a NF, but to require specialized services as defined in paragraphs (B)(34) and (B)(35) of this rule. The thirty months may include temporary absences for hospitalization, therapeutic leave, or visits with family or friends as defined in rule 5101:3-3-16.4 of the Administrative Code.

(15) 'Medicaid managed care plan' means a managed care plan (MCP) as defined in rule 5101:3-26-01 of the Administrative Code.

(16) 'Mental retardation and/or other developmental disabilities (MRDD).' An individual is considered to have mental retardation and/or a developmental disability if he or she has:

(a) A level of retardation described in the american association on mental retardation's manual 'mental retardation: definition, classifications and systems of support' (2002); or

(b) A related condition which means a severe, chronic disability meeting all of the following conditions:

(i) It is attributable to:

(a) Cerebral palsy, epilepsy; or

(b) Any other condition other than mental illness, found to be closely related to mental retardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with mental retardation, and requires treatment or services;

(ii) It is manifested before the person reaches the age of twenty-two; and

(iii) It is likely to continue indefinitely; and

(iv) It results in substantial functional limitations in three or more of the following areas of major life activity:

(a) Self-care;

(b) Understanding and use of language;

(c) Learning;

(d) Mobility;

(e) Self-direction;

(f) Capacity for independent living; or

(g) Economic self-sufficiency (for persons sixteen years and older);

(v) Individuals who have a developmental disability as defined in section 5123.01 of the Revised Code are considered to have a related condition.

(17) 'New admission' means:

(a) The admission, to an Ohio medicaid certified NF, of an individual who was not a resident of any Ohio medicaid certified NF immediately preceding the current NF admission nor immediately preceding a hospital stay from which the individual is to be admitted directly to a NF (this includes individuals with no previous NF admissions; individuals admitted from other states, regardless of type of prior residence; and individuals with prior Ohio NF admissions who had been discharged from an Ohio NF and did not have either an intervening hospital or other NF stay immediately preceding the current NF admission); and/or

(b) The admission, with or without an intervening hospital stay, to an Ohio medicaid certified NF, of an individual discharged, returning to the same NF or transferred from an Ohio medicaid certified NF subsequent to an adverse PAS or RR determination or following an overruled appeal of an adverse PAS or RR determination immediately preceding the current NF admission; and/or

(c) For PASRR purposes only and effective on the date the facility submits its application packet for medicaid certification to ODJFS, individuals seeking admission to, or are currently residing in, a facility that is in the process of obtaining its initial medicaid certification by Ohio department of health (ODH) and that facility and its residents were not subject to PASRR requirements preceding the submission of this application for medicaid certification. This does not include facilities that have already received medicaid NF certification and are undergoing a change of operator; and/or

(d) With the exception of those circumstances specified in paragraphs (B)(17)(a) to (B)(17)(c) of this rule, NF transfers and readmissions as defined in paragraphs (B)(19) and (B)(25) of this rule are not considered to be new admissions for the purposes of this rule.

(18) 'Nursing facility' has the same meaning as in section 5111.20 of the Revised Code. A long term care facility that has submitted an application packet for medicaid certification to ODJFS is considered to be in the process of obtaining its initial medicaid certification by the ODH and shall be treated as a NF for the purposes of this rule.

(19) 'NF transfer.' A NF transfer occurs when an individual's place of residence is changed from any Ohio medicaid certified NF to another Ohio medicaid certified NF, with or without an intervening hospital stay.

(20) 'Preadmission screening identification (PAS/ID).' 'PAS/ID', also known as a level one screen, means the process by which ODJFS, or its designee, screens individuals who are seeking new admissions to identify those who have indications of mental retardation and/or other developmental disabilities (MR/DD) or serious mental illness (SMI) as defined in paragraphs (B)(11) and (B)(12) of this rule; and who, therefore, must be further evaluated by ODMH and/or DODD.

(21) 'Physician' means a doctor of medicine or osteopathy who is licensed to practice medicine.

(22) 'Preadmission screening for mental retardation/developmental disabilities (PAS-MRDD), also known as a level two screen, means the process by which DODD determines:

(a) Whether, due to the individual's physical and mental condition, an individual who has MRDD requires the level of services provided by a NF or another type of setting; and

(b) If the level of services provided by a NF is needed, whether the individual requires specialized services for MRDD.

(23) 'Preadmission screening for serious mental illness (PAS/SMI), also known as a level two screen, means the process by which ODMH determines:

(a) Whether, due to the individual's physical and mental condition, an individual who has SMI requires the level of services provided by a NF or another type of setting; and

(b) Whether the individual requires specialized services for serious mental illness.

(24) Preadmission screening (PAS) means the pre-admission portion of the PASRR requirements mandated by section 1919(e)(7) of the Social Security Act, which must be implemented in accordance with rules 5101:3-3-15.1, 5122-21-03 and 5123:2-14-01 of the Administrative Code.

(25) 'Readmission' means the individual is readmitted to the same NF, following a stay in the hospital to which he or she was sent for the purpose of receiving care, except as specified in paragraphs (B)(17)(a) to (B)(17)(d) of this rule.

(26) 'Resident review (RR)' means the resident review portion of the PASRR requirements mandated by section 1919(e)(7) of the Social Security Act, which must be implemented in accordance with rules 5101:3-3-15.2, 5122-21-03 and 5123:2-14-01 of the Administrative Code.

(27) 'Respite NF stay' means the admission of an individual to a NF for a maximum of fourteen days in order to provide respite to in-home caregivers to whom the individual is expected to return following the brief respite stay.

(28) 'RR identification (RR/ID)' is the process set forth in rules 5101:3-3-15.2, 5122-21-03 , and 5123:2-14-01 of the Administrative Code by which individuals who are subject to RR shall be identified.

(29) 'Resident review for mental retardation/developmental disabilities (RR-MRDD)' means the process, set forth in rule 5123:2-14-01 of the Administrative Code, by which the DODD determines whether, due to the individual's physical and mental condition, an individual who is subject to RR, and who has mental retardation/developmental disabilities (MRDD) requires the level of services provided by a NF or another type of setting; and, whether the individual requires specialized services for MRDD.

(30) 'Resident review for serious mental illness (RR-SMI)' means the process, set forth in rule 5122-21-03 of the Administrative Code, by which the ODMH determines whether, due to the individual's physical and mental condition, an individual who is subject to RR, and who has serious mental illness (SMI) requires the level of services provided by a NF or another type of setting; or whether that individual requires specialized services for serious mental illness.

(31) 'Ruled out' means that the individual has been determined not to be subject to further review by DODD or ODMH. An individual may be ruled out for further PASRR review at any point in the PASRR process. If DODD or ODMH finds at any time during the evaluation that the individual being evaluated:

(a) Does not have MRDD or SMI; or

(b) Has a primary diagnosis of dementia (including alzheimer's disease or a related disorder); or

(c) has a non-primary diagnosis of dementia without a primary diagnosis that is serious mental illness, and does not have a diagnosis of MRDD or a related condition.

(32) 'Serious mental illness (SMI)' includes the following criteria regarding diagnosis, level of impairment and recent treatment.

(a) Diagnosis. The individual does not have dementia (as defined in paragraph (B)(6) of this rule), but has a major mental disorder diagnosable under the 'Diagnostic and statistical manual of mental disorders,' fourth edition, text revision (DSM-IV-TR); and this mental disorder is one of the following: a schizophrenic, mood, delusional (paranoid), panic or other severe anxiety disorder, somatoform disorder, personality disorder, other psychotic disorder, or another mental disorder other than mental retardation that may lead to a chronic disability diagnosable under the DSM-IV-TR .

(b) Level of impairment. Within the past six months, due to the mental disorder, the individual has experienced functional limitations on a continuing or intermittent basis in major life activities that would be appropriate for the individual's developmental stage.

(c) Recent treatment. The treatment history indicates that the individual has experienced at least one of the following:

(i) Psychiatric treatment more intensive than counseling and/or psychotherapy performed on an outpatient basis more than once within the past two years; or

(ii) Within the last two years, due to the mental disorder, experienced an episode of significant disruption to the usual living arrangement, for which supportive services were required, or which resulted in intervention by housing or law enforcement officials.

(33) Significant change of condition including any major decline or improvement in condition has the same meaning used in administering the routine resident assessment requirements specified in 42 C.F.R. 483.20 , and that at least one of the following criteria is met:

(a) There is a change in the individual's current diagnosis(es), mental health treatment, functional capacity, or behavior such that, as a result of the change, the individual who did not previously have indications of SMI, or who did not previously have indications of MRDD, now has such indications (this includes any individual who may have had indications of one or the other but now has indications of both SMI and MRDD), or who was previously determined by ODMH not to have SMI but who now meets all three of the defining criteria for SMI (set forth in paragraphs (B)(3)(a)(i) to (B)(3)(a)(iii) of rule 5101:3-3-15.1 of the Administrative Code); or

(b) The change is such that it may impact the mental health treatment or placement options of an individual previously identified as having SMI and/or may result in a change in the specialized services needs of an individual previously identified as having MRDD.

(34) 'Specialized services for serious mental illness' means those services which are distinct from those available in NFs and results in the continuous and aggressive implementation of an individualized plan of care approved by the medical director of ODMH or designee that:

(a) Is developed and supervised by an interdisciplinary team which includes a physician, trained mental health professionals and, as appropriate, other professionals;

(b) Prescribes specific therapies and treatment activities for an individual experiencing an acute episode of SMI which necessitates supervision by trained mental health personnel in an inpatient setting licensed and/or operated by ODMH; and

(c) Is time limited and directed toward diagnosing and reducing the individual's behavioral symptoms that necessitated intensive and aggressive intervention, improving the individual's level of independent functioning, and achieving a functioning level that permitting reduction in the intensity of mental health services to below the level of specialized services at the earliest possible time.

(35) 'Specialized services for mental retardation and/or other developmental disabilities' means the services specified by the PAS-MRDD or RR-M/DD determination and provided or arranged for by the CBDD resulting in continuous active treatment to address needs in each of the life areas in which functional limitations are identified by the CBDD. Specialized services shall be made available at the intensity and frequency necessary to meet the needs of the individual.

Effective: 12/01/2009
R.C. 119.032 review dates: 12/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.02

5160-3-15.1 Preadmission screening (PAS) requirements for individuals seeking admission to nursing facilities (NFs).

(A) The purpose of this rule is to set forth the PAS requirements in order to comply with section 1919(e)(7) of the Social Security Act, as amended, which prohibits nursing facilities from admitting or enrolling individuals with serious mental illness (SMI) (as defined in paragraph (B)(32) of rule 5101:3-3-14 of the Administrative Code) or mental retardation and/or other developmental disabilities (MRDD) (as defined in paragraph (B)(16) of rule 5101:3-3-14 of the Administrative Code) unless a thorough evaluation indicates that such placement is appropriate and adequate services will be provided.

(B) Preadmission screening identification (PAS/ID) requirements:

(1) PAS/ID must be completed prior to any new admission to a NF and prior to any categorical determination as these are defined in rule 5101:3-3-14 of the Administrative Code unless the admission meets the criteria for a hospital(convalescent) exemption as set forth in paragraph (B)(9) of rule 5101:3-3-14 of the Administrative Code and the requirements for exemption set forth in paragraph (G) of this rule.

(2) PAS/ID must be completed and submitted to the PASSPORT administrative agency (PAA), the Ohio department of job and family services (ODJFS) designee, via a JFS 03622 'PASRR (SMI/MRDD) Identification Screen' (rev. 11/09) with supporting documentation sufficient to validate the answers on the JFS 03622.

(a) For individuals seeking medicaid payment, the JFS 03697 'level of care assessment' (rev. 4/03) shall also be submitted in accordance with rule 5101:3-3-15 of the Administrative Code to ODJFS or its designee, unless the individual is enrolled in a medicaid managed care plan(MCP) as defined in rule 5101:3-3-14 of the Administrative Code.

(b) For those individuals who will be relocating from outside of Ohio, who are not Ohio residents, and are known to have serious mental illness (SMI) and/or MRDD or whose JFS 03622 form contains indications of MRDD and/or SMI, the submitter shall obtain and submit with the JFS 03622, the JFS 03697 form, the other state's level two evaluation(s) of the individual and any additional documentation necessary to address the required evaluation elements specified in rules 5122-21-03 and 5123:2-14-01 of the Administrative Code. Submission of the required forms and information does not constitute completion of the PAS/ID process.

(c) For those individuals identified as new admissions in accordance with paragraph (B)(17) of rule 5101:3-3-14 of the Administrative Code who already reside in the facility at the time the PAS/ID is initiated, the submitter must notify ODJFS or its designee of the medicaid status of the facility at the time of the PAS/ID submission.

(d) PAS/ID may be initiated by the individual seeking the new admission, or by another entity on behalf of the individual, or by any state agency or their designee responsible for PAS. The NF is ultimately responsible for ensuring that the PAS/ID is completed and the determination is on file.

(3) ODJFS, or its designee, shall review the JFS 03622 form to determine whether the individual has MRDD and/or indications of SMI.

(a) An individual shall be determined to have indications of SMI if the individual:

(i) Meets at least two of the three criteria specified in paragraph (B)(32) of rule 5101:3-3-14 of the Administrative Code; or

(ii) Due to a mental impairment, receives supplemental security income (SSI) authorized under Title XVI of the Social Security Act, as amended; or

(iii) Due to a mental impairment, receives social security disability insurance (SSDI) authorized under Title II of the Social Security Act, as amended.

(b) An individual shall be determined to have indications of MRDD if the individual's condition meets the defining criteria set forth in paragraph (B)(16) of rule 5101:3-3-14 of the Administrative Code.

(4) PAS/ID results shall determine whether an individual is subject to further review.

(a) Individuals determined to have no indications of SMI and/or MRDD are not subject to further PAS review. Such individuals are considered to have met the PAS requirements effective on the date an accurate and complete record was submitted to ODJFS or its designee, even if the records were received at a later date.

(b) Individuals determined to have indications of SMI shall be subject to further review by the Ohio department of mental health (ODMH), in accordance with rule 5122-21-03 of the Administrative Code. Such individuals shall not be considered to have completed the PAS process until ODMH has issued the PAS/SMI determination.

(c) Individuals determined to have indications of MRDD shall be subject to further review by the Ohio department of developmental disabilities (DODD) in accordance with rule 5123:2-14-01 of the Administrative Code. Such individuals shall not be considered to have completed the PAS process until DODD has issued the PAS/MRDD determination.

(d) Individuals determined to have indications of both SMI and MRDD shall be subject to further review by both ODMH and DODD in accordance with rules 5122-21-03 and 5123:2-14-01 of the Administrative Code. Such individuals shall not be considered to have completed the PAS process until ODMH has issued the PAS/SMI determination and DODD has issued the PAS/MRDD determination.

(e) Any individual twenty-two years of age or older, who has previously been determined by DODD to be ruled out from PAS as defined in paragraph (B)(31) of rule 5101:3-3-14 of the Administrative Code is not subject to further review.

(5) When an individual has been determined to have indications of SMI and/or MRDD, ODJFS or its designee shall forward the JFS 03622 form and all supporting documentation to:

(a) ODMH and/or DODD for categorical and out of state requests. In addition, for those individuals relocating from outside of Ohio, ODJFS or its designee shall also send the other state's evaluation documentation to ODMH and/or DODD.

(b) The county board of DD (CBDD) and/or the ODMH local evaluator, for all other requests.

(6) ODJFS or its designee, ODMH and/or DODD are the only entities that have the authority to render PAS determinations. The individual must not move into an Ohio NF until the PAS determination has been made.

(7) The receiving NFs are responsible for ensuring that all individuals subject to PAS/ID receive a review and determination by ODJFS or its designee and, if applicable, a PAS/SMI review and determination by ODMH and/or a PAS/MRDD review and determination by DODD prior to entering the NF.

(8) NFs who, whether intentionally or otherwise, accept any new admission, readmission, or NF transfer in violation of this rule are in violation of their medicaid provider agreements. This is true regardless of the payment source for the individual's NF stay.

(C) PAS/SMI and PAS/MRDD determination requirements:

(1) There shall be no new admission of any individual with SMI or MRDD, regardless of payment source, unless the individual has either been determined, in accordance with rules 5122-21-03 and /or 5123:2-14-01 of the Administrative Code, to need the level of services provided by a NF, or has qualified for admission under the hospital exemption provision set forth in paragraph (G) of this rule.

(2) PAS/SMI and/or PAS/MRDD must be completed prior to any new admission of an individual determined by ODMH and/or DODD to have SMI and/or MRDD.

(a) For all such individuals identified as new admissions under the provisions of paragraph (B)(17) of rule 5101:3-3-14 of the Administrative Code, and regardless of payment source, the PAS/SMI and/or the PAS/MRDD determination requirements must be met before the individual is admitted to any NF or facility in the process of obtaining its initial medicaid certification and NF provider agreement. Individuals determined not to need NF services shall not be admitted or enrolled and medicaid payment will not be available for NF services.

(b) For all such individuals identified as new admissions under the provisions of paragraph (B)(17)(c) of rule 5101:3-3-14 of the Administrative Code who are current residents of the facility, the PAS/SMI and/or the PAS/MRDD requirements must be met prior to the effective date of the NF provider agreement between ODJFS and the newly certified NF and/or prior to the availability of medicaid payment for the medicaid eligible individual.

(3) ODMH and DODD are prohibited from utilizing criteria relating to the need for NF care or specialized services that are inconsistent with C.F.R. 483.108 and the ODJFS approved state plan for medicaid. The approved state plan for medicaid includes level of care criteria, contained in Chapter 5101:3-3 of the Administrative Code. Therefore, ODMH and DODD must use criteria consistent with Chapter 5101:3-3 of the Administrative Code in making their determinations regarding whether individuals with SMI and/or MRDD need the level of services provided by a NF.

(D) PAS/ID, PAS/SMI, and PAS/MRDD requests for additional information:

(1) ODJFS or its designee, ODMH and/or DODD may request any additional information required in order to make an PAS determination.

(2) If ODJFS or its designee, ODMH and/or DODD require additional information in order to make the PAS determination they shall provide written notice to the NF, the individual, the hospital, the referring entity, and the individual's representative, if applicable. This notice shall specify the missing forms, data elements and other documentation needed to make the required determinations.

(3) In the event the individual and/or other entity does not provide the necessary information within fourteen calendar days, ODJFS or its designee, ODMH and/or DODD shall provide written notice to the individual, the individual's guardian or authorized representative, if applicable, and the NF that the admission is prohibited due to failure to provide information necessary for the completion of the PAS process and that the individual may appeal the determination in accordance with the provisions of division 5101:6 of the Administrative Code. The individual, regardless of payment source, must not be admitted to the NF.

(4) If the individual was seeking medicaid coverage of the proposed NF stay, the county department of job and family services (CDJFS) must also be notified that the individual is not eligible for the admission due to failure to cooperate in the establishment of eligibility.

(5) If the individual or other entity submits the requested information within the timeframes specified in the notice, ODJFS or its designee, or DODD and/or ODMH shall continue with the PAS process.

(E) PAS/ID, PAS/SMI, and PAS/MRDD notification:

(1) In accordance with all requirements specified in rule 5101:6-2-32 of the Administrative Code, ODJFS, or its designee, shall report the outcome of the PAS/ID to the individual, their guardian, or authorized representative (if applicable) and to the entity which initiated the review, and the applicable state department(s) who receive the JFS 03622 and JFS 03697 (if applicable).

(2) The admitting NF shall maintain the results of the PAS/ID in the individual's resident record at the facility.

(3) In accordance with all requirements specified in rule 5101:6-2-32 of the Administrative Code, DODD and/or ODMH must provide written notice of the PAS-MRDD and/or PAS-SMI determination to the individual, their legal guardian of person or authorized representative (if applicable), the individual's physician and the facility. If the individual has applied for medicaid payment of the NF stay, ODJFS and if applicable, the CDJFS and/or the medicaid managed care plan (MCP), must also be notified. If an adverse determination is issued, the facility must then provide the individual, regardless of payment source, with notice of the intent to discharge in accordance with section 3721.16 of the Revised Code.

(4) The admitting NF shall retain the written notification of the PAS/SMI and/or PAS/MRDD determinations received from ODMH and/or DODD in the individual's resident record at the facility.

(F) An individual shall be required to undergo a new PAS/ID in accordance with the provisions of this rule if:

(1) The individual received PAS/ID, PAS/SMI and/or PAS/MRDD that NF services are needed and has not been admitted to a NF within one hundred eighty days for the most recent PAS determination that does not meet the definition in paragraph (B)(3) of rule 5101:3-3-14 of the Administrative Code;

(2) The individual received PAS/SMI and/or PAS/MRDD that NF services are needed and has not been admitted to a NF within the time period specified by ODMH or DODD for a PAS that meets the definition of paragraph (B)(3) of rule 5101:3-3-14 of the Administrative Code.

(G) Hospital (convalescent) exemption from PAS requirements:

(1) The discharging hospital must complete the hospital (convalescent) exemption from preadmission screening notification form (JFS 07000) (11/09). The form must be signed and dated by the attending physician no later than the date of discharge from the hospital certifying that all of the hospital (convalescent) exemption criteria as defined in paragraph (B)(9) of rule 5101:3-3-14 of the Administrative Code have been met.

(2) The discharging hospital must send the completed form to the admitting NF and appropriate PAA.

(3) If the NF accepts the placement of the individual, the NF acknowledges that all three exemption criteria are met as delineated in paragraph (B)(9) of rule 5101:3-3-14 of the Administrative Code.

(4) The admitting NF shall maintain the documentation in the resident's record at the facility.

(5) The NF shall initiate the resident review process, as specified in rule 5101:3-3-15.2 of the Administrative Code, prior to the individual's thirtieth day in the facility.

(6) The PAA shall send a copy of the form to ODMH and/or DODD if the individual has symptoms of SMI and/or a diagnosis of MRDD.

(7) If an individual admitted to a NF under the hospital (convalescent) exemption is admitted to a hospital or transfers to another NF during the first thirty days of their NF stay, the days in the hospital or previous NF will count toward their thirty day hospital (convalescent) exemption time period. A new hospital exemption shall not be granted during the existing exemption time period. A resident review (RR) shall be initiated by the NF in accordance with rule 5101:3-3-15.2 of the Administrative Code if the individual requires a continued NF stay beyond thirty days.

(8) If an adverse determination of either a PAS/SMI, PAS/MRDD, RR/SMI or RR/MRDD determination has been issued by ODMH or DODD within the last sixty calendar days prior to the new admission or enrollment, the individual is not eligible for a hospital exemption and a PAS ID shall be initiated in accordance with paragraph (B)(2) of this rule.

(H) Medicaid payment is not available for NF stays to individuals who are otherwise medicaid-eligible until the date on which the PAS requirements have been met.

(I) Adverse PAS determinations may be appealed in accordance with division 5101:6 of the Administrative Code.

(J) ODJFS has authority to assure compliance with the provisions of this rule. NF's, local administrators, hospitals and all state agencies and their designees shall comply, with accuracy and timeliness, to all requests for records and compliance plans issued by ODJFS or its designees.

Replaces: 5101:3-3- 15.1

Effective: 12/01/2009
R.C. 119.032 review dates: 12/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.202 , 5101.02
Prior Effective Dates: 12/30/88 (Emer.), 3/31/89 (Emer.), 6/30/89, 5/1/93, 1/1/98

5160-3-15.2 Resident review (RR) requirements for individuals residing in nursing facilities (NFs).

(A) The purpose of this rule is to set forth the RR requirements which must be met in order to comply with section 1919 (e)(7) of the Social Security Act, as amended which prohibits nursing facilities from retaining individuals with serious mental illness (SMI) (as defined in paragraph (B)(32) of rule 5101:3-3-14 of the Administrative Code) or mental retardation and/or other developmental disabilities (MRDD) (as defined in paragraph (B)(16) of rule 5101:3-3-14 of the Administrative Code) unless a thorough evaluation indicates that such placement is appropriate and adequate services are provided.

(B) Resident review identification (RR/ID) is required for all individuals who meet any of the following criteria:

(1) The individual was admitted under the exemption from preadmission identification (PAS/ID) provision set forth in paragraph (C) of rule 5101:3-3-15.1 of the Administrative Code, and has since been found to require more than thirty days of services at the NF level; or

(2) The individual's admission is a NF transfer, as defined in paragraph (B)(19) of rule 5101:3-3-14 of the Administrative Code, or a NF readmission as defined in paragraph (B)(25) of rule 5101:3-3-14 of the Administrative Code and there are no PASRR records available from the previous NF placement.

(3) The individual had been in a different NF and was admitted directly following an intervening hospital stay for psychiatric treatment, or was readmitted to the same NF directly following a hospital stay for psychiatric treatment, and since the last PASRR determination, has experienced a significant change in condition as defined in paragraph (B)(33) of rule 5101:3-3-14 of the Administrative Code; or

(4) The individual has experienced a significant change in condition as defined in paragraph (B)(33) of rule 5101:3-3-14 of the Administrative Code; or

(5) The individual received a categorical PAS-SMI or PAS-MRDD determination as defined in paragraph (B)(3) of rule 5101:3-3-14 of the Administrative Code, and has since been found to require a stay in a NF that will exceed the specified time limit for that category; or

(6) The individual received an RR determination for a specified period of time as established by the Ohio department of developmental disabilities (DODD) and/or Ohio department of mental health (ODMH) and has since been found to require a stay in a NF exceeding the specified period of time.

(C) RR/ID requirements:

(1) The NF shall initiate a resident review:

(a) For those individuals specified in paragraph (B)(1) of this rule, as soon as (and no later than the twenty-ninth day from the date of admission) the NF has reason to believe the individual may need to remain in a NF for thirty days or more.

(b) For those individuals specified in paragraph (B)(2) of this rule, as soon as the NF finds that no PASRR records are available from the previous NF placement.

(c) For those individuals specified in paragraphs (B)(3) and (B)(4) of this rule, as soon as the NF has reason to believe a significant change may have occurred. The completed RR/ID request for an individual with indications of MRDD or SMI must be submitted to DODD and/or ODMH within seventy-two hours following identification of the significant change.

(d) For those individuals specified in paragraph (B)(5) of this rule, as soon as the NF has reason to believe the individual may need to remain in a NF beyond the expiration date of the categorical determination but no later than the date of the expiration of the categorical determination. If the individual has indications of MRDD and/or SMI, the completed RR/ID request must be submitted to DODD and/or ODMH no later than the expiration date of the categorical determination.

(e) For those individuals specified in paragraph (B)(6) of this rule, at least thirty days prior to the expiration of the determination.

(2) The NF shall initiate the RR/ID via the completion of a PASRR Identification Screen form (JFS 03622) ( rev. 11/09) and is responsible for ensuring that necessary documentation for all individuals subject to RR/ID is submitted timely.

(3) The NF shall review the completed JFS 03622 form to ensure it is completed accurately and to determine whether the individual has indications of SMI and/or MRDD (as defined in paragraphs (B)(3)(a) and (B)(3)(b) of rule 5101:3-3-15.1 of the Administrative Code).

(a) Individuals determined to have indications of SMI shall be subject to further review by the ODMH in accordance with rule 5122-21-03 of the Administrative Code.

(b) Individuals determined to have indications of MRDD shall be subject to further review by the DODD in accordance with rule 5123:2-14-01 of the Administrative Code.

(c) Individuals determined to have indications of both SMI and MRDD shall be subject to further review by both ODMH and DODD in accordance with this rule and rules 5122-21-03 and 5123:2-14-01 of the Administrative Code.

(d) Individuals determined to have no indications of SMI and/or MRDD are not subject to further RR review.

(4) Routing of completed JFS 03622 and supporting documentation:

(a) For individuals determined to have no indications of either MRDD or SMI, the NF shall place and maintain the JFS 03622 and all supporting evidence in the resident's record at the facility.

(b) For individuals determined to have indications of either or both SMI and MRDD, the NF shall timely submit to ODMH and DODD the JFS 03622 form, documentation supporting the JFS 03622, as well as documentation of the individual's current condition and evidence of the individual's need for services at the NF level. If medicaid is the payer, such documentation must also include the JFS 03697, 'level of care assessment' form (rev. 4/03 ).

(c) For individuals determined to have indications of MRDD and/or SMI, the NF is responsible for the accurate and timely submission of the RR/ID request to DODD and/or ODMH in accordance with the provisions of this rule.

(5) If the individual is subject to RR/SMI and/or RR-MRDD and there is no record of the determinations in the medical record and/or no indication that they are in progress, the NF shall notify ODMH and/or DODD.

(6) If an individual who is subject to RR/ID has indications of MRDD and/or SMI and is discharged from the NF after submission of the RR/ID request but prior to the determination, and/or prior to the due date for the request, the NF will notify DODD and/or ODMH.

(7) If an individual is to be transferred to another Ohio NF after submission of the RR/ID request but prior to receipt of the RR/ID, RR/MRDD and/or RR/SMI determinations:

(a) The sending NF must notify DODD and/or ODMH of the transfer. Such notice must be written and must be provided to DODD and/or ODMH not later than the day the individual is transferred. The sending NF must provide sufficient contact information to enable the completion of the RR process.

(b) At or prior to the time the individual is transferred, the sending NF must also provide the receiving NF with copies of all PASRR related documents pertaining to the individual and written notice of the individual's current status with regard to PASRR. If known, the notice must include contact information for the RR evaluator assigned by ODMH and/or DODD.

(c) The receiving NF must not accept the individual as a NF transfer unless it receives this information at or prior to the time the individual is admitted to the receiving NF.

(d) If the transferring individual is medicaid eligible at the time of the transfer, the sending NF must also provide written notice of the transfer and the current PASRR status of the individual to ODJFS or its designee. Such notice must be provided no later than the date on which the individual is transferred.

(8) NFs that, intentionally or otherwise, accept any readmission or NF transfer, or retain as a resident any individual in violation of this rule are in violation of their medicaid provider agreements. This is true regardless of the payment source for the individual's NF stay.

(9) If it is determined that the NF failed to initiate the RR/ID in accordance with this rule, an RR/ID may be initiated by the individual or by any state agency or their designee responsible for PASRR or by another entity on behalf of the individual. The NF is ultimately responsible to ensure that the RR/ID is completed and the determination is on file.

(10) Individuals who have indications of SMI or MRDD shall not be considered to have completed the RR process until ODMH and/or DODD have issued the RR/SMI and/or RR/MRDD determinations.

(11) The NF shall maintain the results of the RR/ID in the individual's resident record at the facility.

(D) RR/SMI and RR/MRDD determination requirements:

(1) No individual with SMI or MRDD shall be retained as a resident in a NF, regardless of payment source, unless it has been determined, in accordance with rules 5122-21-03 and 5123:2-14-01 of the Administrative Code, that:

(a) The individual needs the level of services provided by a NF; or

(b) The individual had resided in a NF for at least thirty months at the time of the first RR determination that the individual does not require the level of services provided by a NF and requires specialized services only; and the individual has chosen to remain in a NF following receipt of information pertaining to service alternatives to nursing facility placement.

(2) ODMH and/or DODD may approve a determination that the level of services provided by a NF are needed to best meet the individual's needs long term and for an unspecified period of time.

(3) ODMH and/or DODD may approve a determination that the level of services provided by a NF are needed short term and for a specified period of time in order to meet the individual's needs.

(a) ODMH and/or DODD may approve such a determination for no more than one hundred eighty days.

(b) ODMH and/or DODD shall not issue an extension to the initial determination without ODJFS approval. Extensions shall not exceed ninety days.

(c) In conjunction with local entities, the NF shall initiate and continue discharge planning activities throughout the period of time specified on the determination notice.

(d) In order to receive consideration for an extension to the initial determination, the NF shall initiate an RR/ID at least thirty days prior to the expiration of the determination. A request for an extension shall include documentation of discharge planning activities. The written record of discharge planning activities shall include the alternative settings and services explored and the steps taken to ensure that a safe and orderly discharge occurs.

(4) RR/SMI is required for all individuals who were determined by ODMH during the RR/ID, in accordance with this rule and rule 5122-21-03 of the Administrative Code, to have SMI.

(5) RR-MR/DD is required for all individuals who were determined by DODD during the RR/ID in accordance with this rule and rule 5123:2-14-01 of the Administrative Code, to have MRDD.

(6) Individuals with both SMI and MRDD are subject to both RR/SMI and RR-MRDD.

(7) ODMH and/or DODD are prohibited from utilizing criteria relating to the need for NF care or specialized services that are inconsistent with the statute and the ODJFS approved state plan for medicaid. The approved state plan for medicaid includes level of care criteria, contained in Chapter 5101:3-3 of the Administrative Code. Therefore, ODMH and DODD must use criteria consistent with Chapter 5101:3-3 of the Administrative Code in making their determinations regarding whether individuals with SMI and/or MRDD need the level of services provided by a NF.

(8) Any individual twenty-two years of age or older, who has previously been determined by DODD to be ruled out from PAS as defined in paragraph (B)(31) of rule 5101:3-3-14 of the Administrative Code are not subject to further review.

(9) An RR determination is not a level of care determination. Individuals seeking medicaid payment for the NF stay shall meet the level of care requirements in accordance with division 5101:3 of the Administrative Code.

(E) RR/ID, RR/SMI, and RR/MRDD requests for additional information:

(1) ODMH and/or DODD may request any additional information required in order to make an RR determination.

(2) If ODMH and/or DODD require additional information in order to make the RR determination they shall provide written notice to the NF, the individual, and the individual's representative, if applicable. This notice shall specify the missing forms, data elements and/or other documentation that are needed to make the required determinations.

(3) In the event the individual and/or other entity does not provide the necessary information within fourteen calendar days, the agency that requested the information shall provide written notice to the individual, the individual's representative, if applicable, and the NF that a continued stay at the NF is prohibited due to failure to provide information necessary for the completion of the RR process and that the individual may appeal the determination in accordance with the provisions of division 5101:6 of the Administrative Code.

(F) RR/ID, RR/SMI, and RR/MRDD notification:

(1) In accordance with all requirements specified in rule 5101:6-2-32 of the Administrative Code, ODMH and/or DODD shall provide written notification of all RR/SMI and/or RR-MRDD determinations made.

(a) Such written notice shall be provided to:

(i) The evaluated individual and his or her legal representative;

(ii) The NF in which the individual is a resident; and

(iii) The individual's attending physician.

(iv) In the case of an adverse determination and an approval which is issued for a specified period of time ODJFS and the medicaid managed care plan as defined in rule 5101:3-3-14 of the Administrative Code and the CDJFS, when applicable.

(b) Such written notice shall include all of the following components:

(i) The determination as to whether and when applicable, for how long the individual requires the level of services provided by a NF;

(ii) The determination as to whether the individual requires specialized services for SMI and/or MRDD;

(iii) The placement and/or service options that are available to the individual consistent with those determinations; and

(iv) The individual's right to appeal the determination(s).

(2) Upon receipt of the written notice of an adverse determination, the NF shall provide the individual with notice of the intent to discharge. When an expiration date is specified in the written notice, the NF shall provide the individual with notice of the intent to discharge at least thirty days prior to the expiration date. All individuals, regardless of payment source, who are subject to RR/SMI and/or RR/MRDD and who do not meet the retention criteria set forth in paragraph (D)(1) of this rule must be discharged from the NF and relocated to an appropriate setting in accordance with section 3721.16 of the Revised Code. The NF shall maintain a written record of discharge planning activities which shall include the alternative settings and services explored and the steps taken to ensure that a safe and orderly discharge occurs.

(3) The NF shall retain the written notification of the RR/SMI and/or RR-MRDD determinations received from ODMH and/or DODD in the individual's resident record at the facility.

(G) Medicaid payment for services

(1) Medicaid payment is not available for the provision of specialized services for SMI and/or MRDD.

(2) Medicaid payment is available for the provision of NF services to medicaid-eligible individuals subject to RR/SMI and/or RR-MRDD only when the individual has met the criteria for retention set forth in paragraph (D)(1) of this rule.

(3) For medicaid eligible individuals, medicaid payment is available through the time period specified in the notice or during the period an appeal is in progress.

(4) When a RR/ID is not initiated by the NF within the timeframes specified in paragraph (C )(1) of this rule, but is performed at a later date, medicaid payment is not available for services furnished to the eligible individual from the date the RR/ID was due through the earlier of:

(a) If the individual had indications of MRDD or SMI the seventh calendar day following the receipt of the JFS 03622 form by ODMH or DODD; or

(b) If the individual had no indications of MRDD or SMI, the date the RR/ID determination was made;

(H) Adverse determinations may be appealed in accordance with division 5101:6 of the Administrative Code.

(I) ODJFS has authority to assure compliance with the provisions of this rule. NF's, local administrators, hospitals and all state agencies and their designees shall comply, with accuracy and timeliness, to all requests for records and compliance plans issued by ODJFS or its designees.

Replaces: 51010:3-3- 15.2

Effective: 12/01/2009
R.C. 119.032 review dates: 12/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.202 , 5101.02
Prior Effective Dates: 5/1/93, 1/1/98

5160-3-15.3 Level of care review process for intermediate care facilities for the mentally retarded.

(A) "Level of care review", as used in this rule, is an assessment of an individual's physical, mental, habilitative and social/emotional needs to determine whether the individual requires intermediate care facility services for the mentally retarded. Level of care (LOC) review is conducted pursuant to paragraph 1902(a)(30)(A) of the Social Security Act and are those activities necessary to safeguard against unnecessary utilization. "Intermediate care facility services for the mentally retarded" are those services available in facilities certified as intermediate care facilities for the mentally retarded (ICF-MR) by the Ohio department of health.

The evaluation of an individual's LOC needs determines the appropriately certified facility type for which medicaid vendor payment can be made. Except as provided in paragraph (D) of this rule, vendor payment can be initiated to an ICF-MR only when the applicant is determined to need an ICF-MR LOC according to the criteria specified in rule 5101:3-3-07 of the Administrative Code.

(B) Definitions:

(1) "CDHS" means county department of human services.

(2) "ICF-MR" means intermediate care facility for the mentally retarded. An "ICF-MR" is a long term care facility certified to provide services to individuals with mental retardation or a related condition who require active treatment as defined at 42 CFR 483.440 . In order to be eligible for vendor payment in an ICF-MR, a medicaid recipient must be assessed and determined by ODHS to be in need of an ICF-MR level of care as outlined in rule 5101: 3-3-07 of the Administrative Code.

(3) "Individual" means a medicaid recipient or person with pending medicaid eligibility who is making application to a nursing facility (NF) or ICF-MR; or who resides in a NF or an ICF-MR; or is applying for home and community-based services (HCBS) waiver enrollment.

(4) "Physician" means a doctor of medicine or osteopathy who is licensed to practice medicine in the state of Ohio.

(5) "Psychologist" means a degreed psychologist who has been licensed by the Ohio board of psychology to practice psychology in the state of Ohio.

(C) Level of care review is required for individuals in the following situations:

(1) Hospitalized individuals who are not currently ICF-MR residents who are applying for ICF-MR placement.

(2) Hospitalized individuals who are current ICF-MR residents who are seeking admission to a different ICF-MR.

(3) Individuals seeking readmission to the ICF-MR after exhausting available paid hospital leave days (see rule 5101:3-3-03 of the Administrative Code requirements regarding available leave days).

(4) Individuals who are current ICF-MR residents who are seeking admission to a different ICF-MR.

(5) Individuals who are not currently ICF-MR residents who are seeking admission to an ICF-MR from community living arrangements.

(6) Individuals who were on paid leave days are not in a hospital setting and who have exhausted their paid leave days, who are seeking readmission to an ICF-MR.

(7) Current ICF-MR residents who are requesting medicaid reimbursement of their ICF-MR stay.

(8) Individuals applying for HCBS waiver services.

(D) Under the circumstances in paragraphs (D)(1), (D)(2) and (D)(3) of this rule, vendor payment shall be continued or reinstated when a change in institutional setting is sought.

(1) Current ICF-MR residents receiving medicaid vendor payment who wish to transfer to another ICF-MR must submit a completed ODHS 3697 form, not later than the day of transfer to the new ICF-MR, as specified in paragraphs (E)(1) and (E)(2) of this rule to initiate reimbursement in the new ICF-MR effective from the date of admission.

(a) Under this circumstance, vendor payment to the new ICF-MR will be authorized back to the date of the individual's admission to the facility. ODHS shall notify the appropriate CDHS to begin vendor payment. If ODHS determines that the individual is no longer in need of an ICF-MR LOC, ODHS will notify the recipient and the ICF-MR as to the adverse ODHS determination and ODHS's intent to terminate vendor payment. The notice shall set forth the recipient's hearing rights and the time frames within which they must be exercised. ODHS may instruct the appropriate CDHS, as its designee to issue this notice.

(b) If a hearing request is received in response to the notice specified in paragraph (D)(1)(a) of this rule within time frames specified in rule 5101:1-35-04 of the Administrative Code that require the continuation of benefits, authorization for payment will be continued pending the issuance of a state hearing decision.

(c) If the individual does not submit a hearing request within the time frame specified in paragraph (D)(1)(b) of this rule, vendor payment will automatically terminate on the date specified in the notice advising the recipient of ODHS' intent to terminate vendor payment.

(2) Hospitalized individuals who are current ICF-MR residents and are seeking admission to a different ICF-MR, must meet the requirements in paragraphs (D)(1)(a), (D)(1)(b) and (D)(1)(c) of this rule in order to have vendor payment authorized from the date of admission. These requirements must be met regardless of whether they have exhausted paid leave days.

(3) Hospitalized individuals who are seeking readmission to the same ICF-MR after exhaustion of paid leave days may be readmitted to that ICF-MR regardless of the results of the LOC determination if, not later than the date of readmission, the recipient submits a completed ODHS 3697 form to initiate reimbursement effective from the date of readmission. If the LOC determination does not match the certification of the facility as specified in paragraph (A) of this rule, the following procedures will apply:

(a) Vendor payment to the ICF-MR will be authorized back to the date of the individual's admission to the facility. ODHS shall notify the appropriate CDHS to begin vendor payment. If ODHS determines that the individual is no longer in need of an ICF-MR LOC, ODHS will notify the recipient and the ICF-MR as to the adverse ODHS determination and ODHS' intent to terminate vendor payment. The notice shall set forth the recipient's hearing rights and the time frames within which they must be exercised. ODHS may instruct the appropriate CDHS as its designee to issue this notice.

(b) If a hearing request is received in response to the notice specified in paragraph (D)(3)(a) of this rule within the time frames specified in rule 5101:1-35-04 of the Administrative Code that require the continuation of benefits, authorization for payment will be continued pending the issuance of a state hearing decision.

(c) If the individual does not submit a hearing request within the time frame specified in paragraph (D)(3)(b) of this rule, vendor payment will automatically terminate on the date specified in the notice advising the recipient of ODHS' intent to terminate vendor payment.

(E) In order to obtain a LOC determination, an ODHS 3697, or an alternative form specified by ODHS, which has been appropriately completed, accurately reflects the individual's current mental and physical condition, and is certified by a physician must be submitted for review by ODHS.

(1) The ODHS 3697, or another ODHS-authorized alternative form must include the following components and/or attachments:

(a) Individual's name; medicaid number; date of original admission to the facility, if applicable; current address; name and address of residence if current residence is a licensed or certified residential setting or hospital; and county where the individual's medicaid case is active.

(b) A comprehensive medical, social and psychological evaluation of the individual. The psychological evaluation must be made before admission, but not more than three months before admission. Each evaluation must include:

(i) Diagnosis, including medical, psychiatric and developmental diagnoses, including dates of onset, if the date of onset is significant in determining whether the individual has a developmental disability;

(ii) Summary of medical, social and developmental findings;

(iii) Medical and social family history;

(iv) Mental and physical functional capacity;

(v) Prognoses;

(vi) Kinds of services needed including medical treatments, medications, and other professional medical services;

(vii) Evaluation of the resources available in the home, family and community;

(viii) A physician's certification of the individual's need for ICF-MR care made at the time of admission, or if the individual applies for medicaid while a resident of an ICF-MR, prior to the initiation of vendor payment.

(2) The ODHS 3697 must be complete when it is submitted to ODHS in order for a LOC determination to be made. Any entity (a CDHS, hospital or ICF-MR) who submits a LOC request must ensure that all required components are included before submission.

(a) Following receipt by ODHS of the ODHS 3697, ODHS shall make a determination of whether the ODHS 3697 is sufficiently complete for its personnel to perform the LOC review. If the ODHS 3697 is not complete, ODHS shall notify, in writing, the recipient, the contact person indicated on the ODHS 3697, and the ICF-MR or any other entity responsible for the submission of the ODHS 3697, that additional documentation is necessary in order to complete the LOC review. This notice shall specify the additional documentation that is needed and shall indicate that the individual or another entity has twenty days from the date ODHS mails the notice to submit additional documentation or the ODHS 3697 will be denied for incompleteness with no LOC authorized. In the event an individual or other entity is not able to complete an ODHS 3697 in the time specified, ODHS shall, upon good cause, grant one extension of no more than five days when an extension is requested by the recipient or other entity.

(b) If the ODHS 3697 is complete upon receipt by ODHS, or, if within the periods specified in paragraph (E)(2)(a) of this rule, the recipient submits the required documentation, ODHS shall issue a LOC determination within sixty days of the original receipt of the ODHS 3697 by ODHS. A LOC determination will be issued pursuant to the criteria specified in rules 5101:3-3-05, 5101:3-3-06 and 5101:3-3-07 of the Administrative Code.

(3) A request for an ICF-MR LOC will not be denied by ODHS for the reason that the individual does not need ICF-MR services until a qualified professional whose qualifications include being a registered nurse or a qualified mental retardation professional (as specified at 42 CFR 483.430 ) conducts a face-to-face assessment of the individual, reviews the medical records that accurately reflect the individual's condition for the time period for which payment is being requested; makes a reasonable effort to contact the individual's physician; and investigates and documents alternative community resources including resources available in the home and family which may be available to meet the needs of the individual. Authorized personnel other than the person who conducted the face-to-face assessment will review the face-to-face assessment and make the final LOC decision.

(F) The LOC review process:

(1) ODHS reviews the application material submitted for the individual and completes the payment authorization (ODHS 3670) and sends it, along with the ODHS 3697, to the CDHS designated on the ODHS 3697. The CDHS shall send a copy of the ODHS 3697 and ODHS 3670 to the ICF-MR.

(2) Authorization of payment to an ICF-MR shall correspond with the effective date of the LOC determination specified on the ODHS 3670. This date shall be:

(a) The date of admission to the ICF-MR if it is within thirty days of the physician's signature; or

(b) A date other than that specified in paragraph (F)(2)(a) of this rule. This alternative date may be authorized only upon receipt of a letter which contains a credible explanation for the delay from the originator of the LOC request. If the request is to backdate the LOC more than thirty days from the physician's signature, the physician must verify the continuing accuracy of the information and need for inpatient care by either adding a statement to that effect on the ODHS 3697 or by attaching a separate letter of explanation.

Replaces: 5101:3-3-15

R.C. 119.032 review dates: 4/24/2002 and 04/24/2007

Promulgated Under: 119.03

Statutory Authority: RC 5111.02

Rule Amplifies: RC 5111.01, 5111.02

Prior Effective Dates: 4/7/77, 10/14/77, 7/1/80, 8/1/84, 1/17/92 (Emer.), 4/16/92

5160-3-15.5 ICF-MR Level of care determination process for home and community based medicaid waivers administered by the Ohio department of mental retardation and developmental disabilities.

(A) The purpose of this rule is to describe the level of care review and determination process for all individuals applying for an ICF-MR home and community based medicaid waiver administered by the Ohio department of mental retardation and development disabilities and to describe the annual level of care redetermination process. An ICF-MR level of care determination is required for all individuals as a component of eligibility for ICF-MR home and community based services.

(B) Definitions

(1) "CBMRDD" means a county board of mental retardation and developmental disabilities that has local medicaid administrative authority under section 5126.055 of the Revised Code.

(2) "CDJFS" means a county department of job and family services.

(3) "ICF-MR" means intermediate care facility for the mentally retarded.

(4) "HCBS", as defined in section 5126.01 of the Revised Code means medicaid-funded home and community based services as an alternative to placement in an intermediate care facility for mental retardation provided under a medicaid component that the department of mental retardation and development disabilities administers pursuant to section 5111.871 of the Revised Code.

(5) "ICF-MR home and community based services" means the residential facility waiver, the individual options waiver and any new or amended hcbs waivers that are designed to provide services in lieu of an ICF-MR facility.

(6) "ICF-MR LOC determination" means a decision made by appropriately qualified personnel which establishes that an individual does or does not meet the criteria for an intermediate care facility for the mentally retarded level of care specified in rule 5101:3-3-07 of the Administrative Code.

(7) "Individual" means a medicaid recipient or person with pending medicaid eligibility who is making application for an ICF-MR home and community based waiver.

(8) "ODJFS" means the Ohio department of job and family services.

(9) "ODMRDD" means the Ohio department of mental retardation and developmental disabilities.

(10) "Significant change of condition" means that the individual has experienced a change in physical or mental condition, or functional abilities, or has reached the age of 6 or the age of 16, any of which may result in a change in the individual's level of care.

(C) The CBMRDD, shall, in accordance with section 5126.055 of the Revised Code, coordinate and/or perform evaluations and assessments of the individual and make a recommendation to ODJFS or designee as to whether the individual meets the criteria for an ICF-MR level of care as set forth in rule 5101:3-3-07 of the Administrative Code.

(1) The assessment shall include:

(a) Medical, psychiatric and developmental diagnoses, and dates of onset if the date of onset is significant in determining whether the individual has a developmental disability; and

(b) Review of current functional capacity. This review should be documented on a standard functional assessment form that is approved by the Ohio department of job and family services.

(2) The assessment documentation shall be kept in the official waiver file and made available for state and federal quality assurance and audit purposes.

(D) CBMRDD shall submit a recommendation and supporting documentation described in this section to ODJFS or designee for review and approval or denial of an ICF-MR LOC determination as set forth in rule 5101:3-3-07 of the Administrative Code.

(1) For an initial ICF-MR LOC determination, the cbmrdd shall submit to ODJFS or designee the following documentation supporting the individual's need for an ICF-MR LOC:

(a) A medical evaluation which includes etiology of the condition leading to a developmental disability, diagnoses, and dates of onset, completed by a doctor of medicine or osteopathy who is licensed by the state of Ohio medical board.

(b) A psychological evaluation completed by a psychologist who has been licensed by the Ohio board of psychology to practice psychology in the state of Ohio, or a psychiatric evaluation completed by a psychiatrist licensed to practice psychiatry by the state of Ohio medical board, which includes the most current diagnoses as specified in the most current diagnostic statistical manual of mental disorders, axes I, II and III.

(c) ICF-MR LOC eligibility determination form as approved by ODJFS.

(2) The CBMRDD shall submit an ICF-MR LOC redetermination to ODJFS or designee within twelve months of the initial LOC determination, and every year thereafter, and upon a significant change of the individual's condition, as defined in paragraph (B) (10) of this rule, which will establish one of the following:

(a) The individual has not had a significant change in condition. The cbmrdd shall submit the appropriate ICF-MR LOC redetermination form verifying that the individual's condition has not changed significantly since the initial loc determination and shall recommend continuation of the ICF-MR LOC; or

(b) The individual has experienced a significant change of condition from the time of the initial ICF-MR LOC determination. The CBMRDD shall reassess the individual's needs and submit new evaluations which verify the change in condition with the appropriate ICF-MR LOC redetermination form. This redetermination should be completed as soon as a significant change in condition has occurred.

(E) Following receipt by ODJFS or designee of the documentation specified in paragraph (D) (1)(c) of this rule, ODJFS or designee shall make a determination of whether the documentation is sufficiently complete for its personnel to perform the ICF-MR LOC review and make a determination based upon the criteria set forth in rule 5101:3-3-07 of the Administrative Code.

(1) If the documentation is not complete, ODJFS or designee shall notify the individual and the CBMRDD regarding the need for additional documentation. This notice shall specify the additional documentation that is required and shall indicate that the individual, or someone on their behalf, has twenty days from the date ODJFS or designee mails the notice to submit additional documentation or the authorized form will be denied for incompleteness with no ICF-MR LOC authorized. In the event an individual, or someone on their behalf, is not able to complete an authorized form in the time specified, ODJFS or designee shall, upon good cause, grant an extension when an extension is requested by the individual or someone on their behalf.

(2) Within thirty days of receipt of all required documentation, ODJFS or designee shall issue an ICF-MR LOC determination. An ICF-MR LOC determination will be issued pursuant to the criteria as set forth in rule 5101:3-3-07 of the Administrative Code.

(3) A request for an ICF-MR LOC will not be denied by ODJFS or designee for the reason that the individual does not meet the ICF-MR LOC criteria, as set forth in rule 5101:3-3-07 of the Administrative Code, until a qualified professional, whose qualifications include being a registered nurse or a qualified mental retardation professional, as specified at 42 C.F.R 483.430 , conducts a face-to-face assessment of the individual and reviews the medical records that accurately reflect the individual's condition. Authorized personnel other than the person who conducted the face-to-face assessment will review the face-to-face assessment and make the final ICF-MR LOC determination.

(F) Once a final ICF-MR LOC determination is made, ODJFS or designee shall notify the individual. The notice shall establish the individual's hearing rights, as set forth in rule 5101:6-2-02 to 5101:6-2-04 of the Administrative Code, and the time frames within which they must be exercised.

(1) If a hearing request is received in response to the notice specified in paragraph (F) of this rule and within the time frames specified in rule 5101:6-4-01 of the Administrative Code that require the continuation of benefits, authorization for payment will be continued pending the issuance of a state hearing decision.

(2) If the individual does not submit a hearing request within the time frame specified in paragraph (F) of this rule, vendor payment will automatically terminate on the date specified in the notice advising the recipient of ODJFS' intent to terminate vendor payment.

(G) Federal financial participation (FFP) shall not be claimed for ICF-MR home and community based waiver services delivered prior to the ICF-MR LOC determination date.

Eff 11-1-01 (Emer.); 1-20-02
Rule promulgated under: RC Chapter 119.
Rule authorized by: RC 5111.02
Rule amplifies: RC 5111.01 , 5111.02
Rule REVIEW DATE: 11/5/01, 11/5/06

5160-3-16 [Rescinded] Resident rights for nursing facilities (NFs).

Effective: 08/15/2014
R.C. 119.032 review dates: 05/19/2014
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 3721.10 , 3721.12 to 3721.17 , 5165.75
Prior Effective Dates: 4/7/77, 7/1/80, 9/24/93 (Emer.), 12/24/93, 7/1/00, 7/1/03, 4/1/08

5160-3-16.1 Resource assessment notice for nursing facilities (NFs).

(A) General.

The JFS 04080 "Medicaid Resource Assessment Notice" (rev. 10/2005) shall conform to all conditions set forth in rule 5101:1-39-35 of the Administrative Code.

(B) Notification.

(1) All NF operators shall furnish written notice at the time of admission to all individuals with a spouse living in the community of the individual's right to have a resource assessment performed by the county department of job and family services (CDJFS). This includes individuals who, at the time of admission, are eligible for the medicare program, or who are covered by a private third party payer.

(2) The NF operator shall do all of the following:

(a) Give a copy of the resource assessment notice to the resident's family member, legal guardian, or authorized agent; and

(b) Send a copy of the signed resource assessment notice to the CDJFS within five working days; and

(c) Post an unsigned copy of the resource assessment notice in a prominent, publicly accessible place within the facility.

(C) Record retention.

A NF operator shall keep a signed copy of the resource assessment notice in a resident's record as long as he or she is a resident of the facility. This copy shall be made available upon request to the staff of the Ohio department of job and family services (ODJFS), the CDJFS, and the Ohio department of health (ODH).

Effective: 01/10/2013
R.C. 119.032 review dates: 04/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01
Prior Effective Dates: 1/1/90 (Emer.), 3/22/90, 1/1/95, 1/2/96 (Emer.), 3/14/96, 5/16/02, 9/29/05, 4/1/08

5160-3-16.2 [Rescinded] Advance directives for nursing facilities (NFs).

Effective: 10/03/2014
Five Year Review (FYR) Dates: 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: Chapters 2133, 1337.
Prior Effective Dates: 1/1/95, 7/1/00, 7/1/03, 4/1/08

5160-3-16.3 Nursing facilities (NFs): private rooms.

(A) Medical necessity.

(1) A nursing facility (NF) operator shall provide private room accommodations for a medicaid eligible resident if the resident requires a private room due to medical necessity.

(2) Medicaid payment shall be considered payment in full, and no supplemental payment may be requested or accepted from a resident or a resident's representative.

(B) Semiprivate or ward accommodations unavailable.

(1) Medicaid shall not pay more for a private room than the current medicaid per diem rate the facility is receiving if semiprivate or ward accommodations are not available.

(2) Medicaid payment shall be considered payment in full, and no supplemental payment may be requested or accepted from a resident or a resident's representative.

(C) Supplemental payment.

If semiprivate or ward accommodations are available and are offered to a resident but the resident or the resident's representative makes a written request for a private room, the private room shall be considered a non-covered service for which the facility may seek supplemental payment from the resident or the resident's representative. Such supplemental payment shall conform to all of the following:

(1) The supplemental payment amount shall represent no more than the difference between the charge to private pay residents for a semiprivate room and the charge to private pay residents for a private room; and

(2) The charge for the private room shall not include charges for services covered by medicaid, whether or not medicaid payment meets a NF operator's cost for the per diem service; and

(3) A NF operator shall detail both monthly and annual supplemental charges, if applicable, on a resident's statement of charges so that the additional cost of a private room is evident to the resident and the resident's family; and

(4) The written request for a private room shall be kept in the resident's file; and

(5) The amount of any supplemental payment shall not be considered an offset in determining patient liability for cost of care. All income that would otherwise be considered available to apply to the cost of care shall continue to be considered available.

Effective: 10/03/2014
Five Year Review (FYR) Dates: 07/01/2014 and 10/03/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 3721.16
Prior Effective Dates: 9/2/82, 1/1/95, 7/1/00, 7/1/03, 4/1/08

5160-3-16.4 Coverage of bed-hold days for medically necessary and other limited absences from nursing facilities (NFs).

(A) Definitions.

(1) "Home and community-based services" (HCBS) means services furnished under the provisions of rule 5101:3-1-06 of the Administrative Code, which enable individuals to live in a community setting rather than in an institutional setting such as a NF, an intermediate care facility for the mentally retarded (ICF-MR), or a hospital.

(2) "Hospitalization" means transfer and admission of a NF resident to a medical institution as defined in paragraph (A)(4) of this rule.

(3) "Institution for mental disease" (IMD) means a hospital, NF, or other institution of more than sixteen beds that is engaged primarily in the diagnosis, treatment, and care of persons with mental diseases, and that provides medical attention, nursing care, and related services. An institution is determined to be an IMD when its overall character is that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such.

(4) "Medical institution" means an institution other than a NF that meets all of the following criteria:

(a) Is organized to provide medical care, including nursing and convalescent care; and

(b) Has the necessary professional personnel, equipment, and facilities to manage the medical, nursing, and other health care needs of patients on a continuing basis in accordance with accepted standards; and

(c) Is authorized under state law to provide medical care; and

(d) Is staffed by professional personnel who are responsible to the institution for professional medical and nursing services. Professional medical and nursing services shall include all of the following:

(i) Adequate and continual medical care and supervision by a physician; and

(ii) Registered nurse or licensed practical nurse supervision and services sufficient to meet nursing care needs; and

(iii) Nurses' aid services sufficient to meet nursing care needs; and

(iv) A physician's guidance on the professional aspects of operating the institution.

(5) "NF admission" means the act that allows an individual who was not considered a resident of any Ohio medicaid certified NF during the time immediately preceding their current NF residence to officially enter a facility to receive NF services. This may include former NF residents who have exhausted their bed-hold days while in the community and/or hospital. A NF admission may be a new admission or a return admission after an official discharge. A NF admission is distinguished from the readmission of a resident on bed-hold status.

(6) "NF bed-hold day," also referred to as "NF leave day," means a day for which a bed is reserved for a NF resident while the resident is temporarily absent from the NF for hospitalization, therapeutic leave days, or visitation with friends or relatives. Payment for NF bed-hold days may be made only if the resident has the intent and ability to return to the same NF. A resident on NF bed-hold day status is not considered discharged from the NF .

(7) "NF discharge" means the full release of a NF resident from the facility, allowing the resident who leaves the facility to no longer be counted in the NF's census. Reasons for NF discharge include but are not limited to the resident's transfer to another facility, exhaustion of NF bed-hold days from any pay source, decision to reside in a community-based setting, or death.

(8) "NF occupied day" means one of the following:

(a) A day of admission; or

(b) A day during which a medicaid eligible resident's stay in a NF is eight hours or more, and for which the facility receives the full per resident per day payment directly from medicaid in accordance with Chapter 5101:3-3 of the Administrative Code.

(9) "NF readmission" means the status of a resident who is readmitted to the same NF following a stay in a hospital to which the resident was sent to receive care, or the status of a resident who returns after a therapeutic program or visit with friends or relatives. A NF resident can only be readmitted to a facility if that individual was not officially discharged from the facility during that NF stay.

(10) "NF therapeutic leave day" means a day that a resident is temporarily absent from a NF with intent and ability to return, and is in a residential setting other than a long-term care facility, hospital, or other entity eligible to receive federal, state, or county funds to maintain a resident, for the purpose of receiving a regimen or program of formal therapeutic services.

(11) "NF transfer" means the events that occur when a person's place of residence changes from one Ohio medicaid certified NF to another, with or without an intervening hospital stay. However, when the person has an intervening IMD admission, or when the person is discharged from a NF during a hospital stay due to exhaustion of available NF bed-hold days and is admitted to a different NF immediately following that hospital stay, the change of residence is not considered a NF transfer.

(12) "Skilled nursing facility" (SNF) means a NF certified to participate in the medicare program.

(B) Prohibition of preadmission NF bed-hold payment.

(1) The office of medical assistance (OMA) shall not make payment to reserve a bed for a medicaid eligible prospective NF resident.

(2) A NF provider shall not accept preadmission bed-hold payments from a medicaid eligible prospective NF resident or from any other source on the prospective resident's behalf as a precondition for NF admission.

(C) Determination of NF bed-hold day or NF occupied day.

To determine whether a specific day during a resident's stay is payable as a NF bed-hold day or a NF occupied day, the following criteria shall be used:

(1) The day of NF admission counts as one occupied day; and

(2) The day of NF discharge is not counted as either a bed-hold or an occupied day; and

(3) When NF admission and NF discharge occur on the same day, the day is considered a day of admission and counts as one occupied day, even if the day is less than eight hours; and

(4) A part of a day in a NF that is eight hours or more counts as one occupied day for reimbursement purposes. A day begins at twelve a.m. and ends at eleven fifty-nine p.m.

(D) Limits and reimbursement for NF bed-hold days.

(1) For medicaid eligible residents in a certified NF, except those described in paragraph (K) of this rule, OMA shall pay the NF provider to reserve a bed only for as long as the resident intends to return to the facility, but for not more than thirty days in any calendar year, and only if the requirements of paragraph (D)(3) of this rule are met.

(2) According to section 5111.331 of the Revised Code, reimbursement for NF bed-hold days shall be paid as follows:

(a) Fifty per cent of the NF provider's per diem rate if the facility had an occupancy rate in the preceding calendar year exceeding ninety-five per cent; or

(b) Eighteen per cent of the NF provider's per diem rate if the facility had an occupancy rate in the preceding calendar year of ninety-five per cent or less.

(3) Reimbursement for NF bed-hold days according to paragraph (D)(2) of this rule shall be considered payment in full, and the NF provider shall not seek supplemental payment from the resident.

(4) Reimbursement for NF bed-hold days shall be made for the following reasons:

(a) Hospitalization.

NF bed-hold days used for hospitalization of NF residents, including NF residents on HCBS waivers, shall be authorized only until:

(i) The day the resident's anticipated level of care (LOC) at the time of NF discharge from the hospital changes to a LOC that the NF provider is not certified to provide; or

(ii) The day the resident is discharged from the hospital, including discharge resulting in transfer to another hospital-based or free-standing NF or SNF; or

(iii) The day the resident decides to go to another NF upon discharge from the hospital and notifies the first NF provider; or

(iv) The day the hospitalized resident dies.

(b) NF therapeutic leave days.

(i) Any plan to use therapeutic leave days must be approved in advance by the resident's primary physician and documented in the resident's medical record. The documentation shall be available for viewing by the county department of job and family services (CDJFS) and OMA staff .

(ii) A NF provider shall make arrangements for the resident to receive required care and services while on approved therapeutic leave, but medicaid shall not pay for care and services that are included in medicaid's continued payments, including but not limited to home health care, personal care services, durable medical equipment (DME), and private duty nursing.

(iii) NF therapeutic leave days are not reimbursable for NF residents who are on an HCBS waiver and do not count towards the annual leave day limit specified in this rule.

(c) Visits with friends or relatives.

(i) Any plan for a limited absence to visit with friends or relatives must be approved in advance by the resident's primary physician and documented in the resident's medical record. The documentation shall be available for viewing by the CDJFS and OMA staff.

(ii) The number of days per visit is flexible within the maximum NF bed-hold days, allowing for differences in the resident's physical condition, the type of visit, and travel time.

(iii) The NF provider shall make arrangements for the resident to receive required care and services while on approved visits, but medicaid shall not pay for care and services that are included in medicaid's continued payments, including but not limited to home health care, personal care services, DME, and private duty nursing.

(iv) Leave days for visits with friends or relatives are not reimbursable for NF residents who are on an HCBS waiver and do not count towards the annual leave day limit specified in this rule.

(5) The number and frequency of NF bed-hold days used shall be considered in evaluating the continuing need of a resident for NF care.

(E) Submission of claims for NF bed-hold days.

A NF provider shall submit claims for NF bed-hold days electronically to OMA in accordance with rule 5101:3-3-39.1 of the Administrative Code.

(F) NF admission after depletion of NF bed-hold days.

(1) A resident who leaves a facility and has already exhausted their bed-hold days is considered in a NF discharge status.

(2) A NF provider shall establish and follow a written policy under which a medicaid resident who has expended their annual allotment of thirty NF bed-hold days, and therefore is no longer entitled to a reserved bed under the medicaid bed-hold limit, and is considered to be discharged, shall be admitted to the first available medicaid certified bed in a semiprivate room.

(a) The first available bed means the first unoccupied bed not being held by a resident (regardless of the source of payment) who has elected to make payment to hold that bed.

(b) Unless involuntary discharge hearing and notice requirements were issued as set forth in section 3721.16 of the Revised Code for the previous admission span, a resident shall be admitted to the first available medicaid certified bed in a semiprivate room even if the resident has an outstanding balance owed to the NF provider from the previous admission. The admitted NF resident may be discharged if the NF provider can demonstrate that nonpayment of charges exists, and if hearing and notice requirements have been issued as set forth in section 3721.16 of the Revised Code.

(3) A medicaid eligible NF resident whose absence from the facility exceeds the bed-hold limit or for whom no bed-hold coverage is available may choose to do one of the following:

(a) Return to the NF upon the availability of the first semiprivate bed in the facility; or

(b) Ensure the timely availability of a specific bed upon return to the facility by making bed-hold payments for any days of absence in excess of the medicaid limit or for which no bed-hold coverage is available. Such payment is separate and distinct from the prohibition of any third party payment guarantee as set forth in rule 5101:3-3-02 of the Administrative Code.

(4) A medicaid eligible resident's NF bed-hold day rights extend only to situations in which the resident leaves the NF for hospitalization, therapeutic leave days, or visits with friends or relatives, and has the intent and ability to return to the same NF.

(a) If a resident who has depleted medicaid covered NF bed-hold days is transferred from a NF to a hospital and then undergoes a NF transfer to a second NF because the second NF provider offers services the first NF provider does not, the first NF provider has no obligation to admit the resident.

(b) If a resident who has depleted medicaid NF bed-hold days is admitted from a NF to a hospital and then is transferred to a hospital-based NF or SNF, the type of NF or SNF to which the resident is transferred does not change the requirements stated in paragraph (F) of this rule. Therefore, a resident transfer to a hospital-based NF or SNF shall be considered the same as a transfer to any other NF or SNF, and the first NF provider has no obligation to admit the resident.

(5) NF admission following the depletion of bed-hold days during a prior stay and subsequent NF discharge requires that a resident has a NF LOC and is eligible for medicaid NF services.

(G) Information and notice prior to leave.

(1) Prior to a resident's use of NF bed-hold days, a NF provider shall furnish the resident and their family member or legal representative written information about the facility's bed-hold policies, which shall be consistent with paragraph (F) of this rule.

(2) At the time a resident is scheduled for a temporary leave of absence, a NF provider shall furnish the resident and their family member or legal representative a written notice that specifies all of the following:

(a) The maximum duration of medicaid covered NF bed-hold days as described in this rule; and

(b) The duration of bed-hold status during which the resident is permitted to return to the NF; and

(c) Whether medicaid payment will be made to hold a bed and if so, for how many days; and

(d) The resident's option to make payments to hold a bed beyond the medicaid bed-hold day limit, and the amount of such payments.

(H) Emergency hospitalization.

(1) In the case of emergency hospitalization, a NF provider shall furnish the resident and a family member or legal representative a written notice as described in paragraph (G) of this rule within twenty-four hours of the hospitalization.

(2) This requirement is met if the resident's copy of the notice is sent to the hospital with other documents that accompany the resident.

(I) Maximum number of NF bed-hold days.

(1) Medicaid payment for covered NF bed-hold days is considered reimbursement for reserving a bed for a resident who intends to return to the same NF and is able to do so.

(2) The number of NF inpatient days as defined in rule 5101:3-3-01 of the Administrative Code for the calendar year shall not exceed one hundred per cent of available bed days.

(J) Residents eligible for payment of NF bed-hold days.

(1) Medicaid payment for NF bed-hold days is available under the provisions specified in this rule if a resident meets all of the following criteria:

(a) Is eligible for medicaid services and has met the patient liability and financial eligibility requirements as stated in rule 5101:1-39-24 of the Administrative Code; and

(b) Requires a NF LOC or is using medicare part A SNF benefits as described in paragraph (J)(2) of this rule; and

(c) Is not a participant of special medicaid programs or assigned special status as outlined in paragraph (K) of this rule.

(2) Dual eligible for both medicare and medicaid.

(a) If a resident meets all of the criteria in paragraph (J)(1) of this rule and is both medicare part A and medicaid eligible, medicaid payment shall be made for NF bed-hold days up to the bed-hold day limit specified in this rule. Medicaid will, therefore, pay NF bed-hold days during the acute care hospitalization of a medicaid eligible resident who had been receiving medicare part A SNF benefits in the NF immediately prior to and/or following the period of hospitalization.

(b) A level of care evaluation is not necessary in the following circumstances:

(i) A medicaid eligible resident receives medicare part A SNF benefits in the NF; or

(ii) A claim for a NF occupied day is submitted on the day the medicare part A covered resident is transferred to the hospital.

(3) Medicaid pending.

If a resident meets all of the criteria in paragraph (J)(1) of this rule, and is pending approval of a medicaid application and requires NF bed-hold days, medicaid payment shall be made retroactive to the date the resident became medicaid eligible and approved for NF medicaid payment, through the date the resident returns from a leave or until the maximum number of NF bed-hold days are exhausted.

(4) Medicaid eligible.

If a resident meets all of the criteria in paragraph (J)(1) of this rule, and is approved for NF medicaid payment, medicaid payment shall be made for NF bed-hold days up to the maximum number of days as specified in this rule.

(5) Qualified medicare beneficiary (QMB) eligible.

If a resident meets all of the criteria in paragraph (J)(1) of this rule and is also QMB eligible, medicaid payment shall be made for NF bed-hold days up to the maximum number of days according to rule 5101:1-39-01.1 of the Administrative Code.

(6) HCBS waiver.

If a resident using the NF for a short-term stay is enrolled in an HCBS waiver program and is not using short-term respite care as a waiver service, medicaid payment shall be made for NF bed-hold days for hospitalization up to the bed-hold day limit specified in this rule. Payment for NF bed-hold days shall not be made for NF residents who are on an HCBS waiver for purposes other than hospitalization.

(K) Exclusions.

NF bed-hold days are not available to medicaid eligible NF residents in the following situations:

(1) Hospice.

A person enrolled in a medicare or medicaid hospice program is not entitled to medicaid covered NF bed-hold days. It is the hospice provider's responsibility to contract with and pay the NF provider. Hospice program provisions and criteria are stated in Chapter 5101:3-56 of the Administrative Code; or

(2) IMD.

A resident over age twenty-one and under age sixty-five who becomes a patient of an IMD loses medicaid eligibility and is not entitled to NF bed-hold days. A NF provider shall not receive reimbursement for NF bed-hold days during the period the person is hospitalized in an IMD. The CDJFS staff shall issue the appropriate notice of medicaid ineligibility as stated in rule 5101:6-2-05 of the Administrative Code; or

(3) HCBS waiver.

NF bed-hold days do not apply to a person enrolled in a HCBS waiver program who is using the NF for short-term respite care as a waiver service. Eligibility criteria for the HCBS waiver program are contained in Chapters 5101:3-12, 5101:3-31, 5101:3-32, 5101:3-33, 5101:3-40, 5101:3-41, 5101:3-42, 5101:3-45, 5101:3-46, 5101:3-47, and 5101:3-50 of the Administrative Code; or

(4) Program of all-inclusive care for the elderly (PACE) or other capitated managed care programs.

NF bed-hold days are not available to a medicaid eligible NF resident who is enrolled in a capitated payment program that subcontracts with a NF and for whom the NF provider does not receive payment directly from medicaid; or

(5) Restricted medicaid coverage.

A person who is medicaid eligible but is in a period of restricted medicaid coverage because of an improper transfer of resources is not eligible for NF bed-hold days until the period of restricted coverage has been met. The criteria for the determination of restricted medicaid coverage are specified in rule 5101:1-39-07 of the Administrative Code; or

(6) Facility closure and resident relocation.

NF bed-hold days are not available to residents who have relocated due to the facility's anticipated closure, voluntary withdrawal from participation in the medicaid program, or other termination of the facility's medicaid provider agreement. No span of NF bed-hold days shall be approved that ends on a facility's date of closure or termination from participation in the medicaid program.

(L) Compliance.

(1) Without limiting such other remedies provided by law for noncompliance with these rules, OMA may do one of the following:

(a) Terminate the NF provider agreement; or

(b) Require the provider to submit and implement a corrective action plan on a schedule specified by OMA.

(2) A NF provider shall cooperate with any investigation and shall provide copies of any records requested by OMA.

Effective: 05/09/2013
R.C. 119.032 review dates: 03/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.331
Prior Effective Dates: 4/7/77, 8/8/77, 9/19/77, 12/30/77, 1/1/79, 1/1/80, 7/1/80, 11/10/83, 4/1/87, 7/7/89 (Emer.), 9/23/89, 1/1/95, 7/1/97, 9/1/02, 7/1/05, 11/15/07, 3/19/12

5160-3-16.5 Personal needs allowance (PNA) accounts and other resident funds for nursing facilities (NFs).

A NF resident's rights concerning his or her personal financial affairs shall be in accordance with 42 CFR 483.10 (rev. October 1, 2006).

(A) Definitions.

(1) "Personal needs allowance" (PNA) has the same meaning as found in rule 5101:1-39-24 of the Administrative Code.

(2) "PNA account" means an account or petty cash fund that holds the money of a NF resident and is managed for the resident by the NF provider.

(3) "Letters of administration," also known as letters testamentary, means court papers allowing a person to take charge of the property of a deceased person in order to distribute it.

(4) "Surety bond" means an agreement between the principal (i.e., the NF provider), the surety (i.e., the insurance company), and the obligee (i.e., the resident and/or the Ohio department of job and family services (ODJFS) acting on behalf of the resident), wherein the principal and the surety agree to compensate the obligee for any loss of the obligee's funds that the principal holds, safeguards, manages, and accounts for.

The purpose of a surety bond is to guarantee that a NF provider will pay a resident, or ODJFS on behalf of a resident, for losses occurring from any failure by the facility to hold, safeguard, manage, and account for the resident's funds, including losses incurred as a result of acts of error or negligence, incompetence, or dishonesty. The principal assumes the responsibility to compensate the obligee for the amount of the loss up to the entire amount of the surety bond.

(B) PNA.

(1) A medicaid resident who receives care in a NF certified to participate in the medicaid program is eligible to retain a PNA account in the amount set forth in rule 5101:1-39-24 of the Administrative Code for the purchase of items and services of his or her choice.

(2) The PNA account is the exclusive property of the resident, who may use the funds in the account as he or she chooses to meet personal needs.

(3) Unless a medicaid resident receives additional irregular contributions from another source, all of his or her personal expenses shall be met through the PNA account.

(C) Management of personal funds.

(1) A NF resident has the right to manage his or her personal financial affairs.

(2) A NF provider shall not require a resident to deposit their PNA funds with the provider. However, if a resident requests assistance from the NF staff in managing his or her PNA account, the request shall be in writing.

(3) Upon written authorization from a resident, a NF shall hold, safeguard, manage, and account for a resident's PNA funds deposited with the provider.

(4) A NF provider shall explain verbally and in writing to the resident or the resident's representative that PNA funds are for the resident to use as he or she chooses. If a representative is the payee for the resident's PNA account, the representative shall be responsible for ensuring that the money is used to meet the personal needs of the resident.

(D) Deposit of PNA account funds and interest earned.

(1) Funds of fifty dollars or less.

If a resident's PNA account funds are fifty dollars or less, a NF provider may deposit the funds in an interest-bearing account, a non-interest bearing account, or a petty cash fund.

(2) Funds in excess of fifty dollars.

If a resident's PNA account funds are in excess of fifty dollars, the NF provider shall deposit the funds in an interest-bearing account (or accounts) that is separate from any of the NF provider's operating accounts within five banking days from the date the balance exceeds fifty dollars.

(3) A NF provider shall credit any interest earned on a resident's PNA funds to the resident's PNA account balance. If pooled accounts are used, the provider shall prorate interest per resident on the basis of actual earnings or end-of-quarter balance.

(4) A NF provider shall not charge a resident a fee for managing the resident's PNA account. Banks, however, may charge the resident a fee for handling the account.

(E) Accounting and records.

(1) A NF provider shall establish and maintain a system that ensures full, complete, and separate accounting of each resident's PNA account funds.

(2) A NF provider shall not commingle a resident's accounts or funds with the provider's accounts or funds, or with the accounts or funds of any individual other than another NF resident.

(3) A NF provider shall provide a resident with access to petty cash (less than fifty dollars) on an ongoing basis and shall arrange for the resident to access larger funds (fifty dollars or more). A NF provider shall give residents a receipt for every transaction, and the NF provider shall retain a copy.

(4) A NF provider shall obtain a resident's signature upon the resident's receipt of PNA funds. If the resident is unable to sign his or her name, he or she shall acknowledge receipt of the money by marking an "X." Two persons shall verify through signature that they have witnessed the resident's action.

(5) A NF provider shall maintain an individual ledger account of revenue and expenses for each PNA account managed by the facility. The ledger account shall meet all the following criteria:

(a) Specify all funds received by or deposited with the NF provider. For PNA account funds deposited in banks, monies shall be credited to the resident's bank account within three business days; and

(b) Specify the dates and reasons for all expenditures; and

(c) Specify at all times the balance due the resident, including interest earned as last reported by the bank to the provider; and

(d) Be available to the resident or the resident's representative for review.

(6) Upon request, a NF provider shall provide receipts to a resident or the resident's representative for purchases made with the resident's PNA funds.

(7) Within thirty days after the end of the quarter, a NF provider shall provide a written quarterly statement to each resident or resident's representative of all financial transactions made by the provider on the resident's behalf.

(F) Notification of certain balances or transactions that may affect medicaid eligibility.

(1) Notice to resident.

(a) A NF provider shall give written notification to each resident who receives medicaid benefits, and whose funds are managed by the NF provider, when the amount in the resident's PNA account reaches two hundred dollars less than the resource limit in accordance with rules 5101:1-39-05 and 5101:1-39-01.1 of the Administrative Code.

(b) The notice shall inform the resident that they may lose medicaid eligibility if the amount in their PNA account, in addition to the value of their other nonexempt resources, reaches their resource limit amount.

(c) A copy of the notice to the resident shall be retained in the resident's file.

(2) Notice to the county department of job and family services (CDJFS).

(a) A NF provider shall report to the CDJFS any PNA account balance in excess of the resource limit. The CDJFS shall apply the excess amount to the routine cost of NF care according to rule 5101:1-38-20 of the Administrative Code.

(3) If a resident is considering using PNA funds to purchase life insurance, grave space, a burial account, or other item that may be considered a countable resource, the NF provider shall refer the resident or the resident's representative to the CDJFS for an explanation of the effect the purchase may have on the resident's medicaid eligibility.

(G) Release of funds upon discharge.

(1) Upon discharge of a resident, a NF provider shall release all the resident's funds, up to and including the maximum resource limit amount.

(2) Other than for items and services that the resident has requested and that may be charged to the resident's PNA account in accordance with this rule, a NF provider shall not withhold PNA account funds to pay any outstanding balance a resident owes the provider at the time of discharge.

(H) Conveyance of funds upon death.

(1) First thirty days.

A NF provider shall not retain the money in a resident's PNA account beyond thirty days following the resident's death if letters testamentary or letters of administration are issued, or an application for release from administration is filed under section 2113.03 of the Revised Code concerning the resident's estate within that thirty-day period. In these circumstances, the provider shall transfer the funds in the resident's PNA account and a final accounting of those funds to the administrator, executor, commissioner, or person who filed the application for release from administration. If these conditions for release are not met, the provider shall follow paragraph (H)(2) or (H)(3) of this rule.

(2) First sixty days.

If, within sixty days after a resident's death, letters testamentary or letters of administration are issued, or an application for release from administration is filed under section 2113.03 of the Revised Code concerning the resident's estate, the provider shall transfer the resident's PNA account funds and a final accounting of those funds to the administrator, executor, commissioner, or person who filed the application for release from administration.

(3) After sixty days.

(a) If, within sixty days after a resident's death, letters testamentary or letters of administration concerning the resident's estate are not issued, or an application for release from administration is not filed under section 2113.03 of the Revised Code concerning the resident's estate, and if the resident was a recipient of medicaid benefits, the provider shall transfer all the resident's PNA account funds to ODJFS no earlier than sixty and no later than ninety days after the death of the resident, with the exception listed in paragraph (H)(3)(c)of this rule.

(b) PNA account funds transferred to ODJFS shall be paid by check or money order made payable to "Attorney General of Ohio" and shall be accompanied by a completed JFS 09405 (rev. 7/2005) entitled "Personal Needs Allowance Account Remittance Notice." The payment and completed JFS 09405 shall be mailed to the Ohio attorney general's office.

(c) If funeral and/or burial expenses for a deceased resident have not been paid, and all the resident's resources other than the PNA have been exhausted, the resident's PNA account funds shall be used to pay the funeral and/or burial expenses.

(d) If, sixty-one or more days after a resident dies, letters testamentary or letters of administration are issued, or an application for release from administration under section 2113.03 of the Revised Code is filed concerning the resident's estate, ODJFS shall transfer all the resident's PNA account funds received by the department to the administrator, executor, commissioner, or person who filed the application for release from administration, unless ODJFS is entitled to recover the money under section 5111.11 of the Revised Code.

(I) Financial security.

A NF provider shall purchase a surety bond or provide a reasonable alternative as described in this rule in order to protect all resident funds deposited with and managed by the NF provider.

(1) Surety bond.

(a) A surety bond shall be executed by a licensed surety company pursuant to Chapters 1301., 1341., and 3929. of the Revised Code.

(b) At a minimum, surety bond coverage shall protect at all times the full amount of resident funds deposited with the NF provider, including interest earned and refundable deposit fees.

(c) The surety bond shall provide for repayment of funds lost due to any failure of the NF provider, whether by commission, bankruptcy, omission, or otherwise, to hold, safeguard, manage, and account for resident funds.

(d) The surety bond shall designate either the NF provider, or ODJFS on behalf of the resident, as the obligee.

(e) If an entity purchases a surety bond that covers more than one of its facilities, the surety bond shall protect the full amount of all resident funds on deposit in all the entity's facilities.

(2) Reasonable alternative to the surety bond.

A reasonable alternative to the surety bond shall provide protection equivalent to that afforded by a surety bond. Neither self insurance nor deposit of funds in bank accounts protected by the federal deposit insurance corporation (FDIC) or a similar entity are acceptable alternatives to a surety bond. A NF provider electing not to purchase a surety bond shall submit a proposal for an alternative to the ODJFS office of Ohio health plans (OHP) for approval. An acceptable alternative shall meet all of the following criteria:

(a) At a minimum, protect at all times the full amount of resident funds deposited with the NF provider, including interest earned and refundable deposit fees; and

(b) Designate either ODJFS or the residents of the NF as the entity or entities that will collect payment for lost funds; and

(c) Guarantee repayment of funds lost due to any failure of the NF provider, whether by commission, bankruptcy, omission, or otherwise, to hold, safeguard, manage, and account for resident funds; and

(d) Be managed by a third party unrelated in any way to the NF provider or its management; and

(e) Not name the NF provider as a beneficiary.

(3) Provision of assurance to ODJFS.

A NF provider or entity who operates multiple facilities shall submit copies of either the multi-facility surety bond or a reasonable alternative to the multi-facility surety bond to ODJFS for review and approval. If the NF provider, surety company, or issuer of an ODJFS-approved surety bond alternative cancels the surety bond or reasonable alternative to a surety bond, they shall notify ODJFS by certified mail thirty days prior to the effective date of cancellation.

(J) Limitations on charges to the PNA account.

(1) A NF provider shall not charge a resident's PNA account for items and services that the provider is required to furnish in order to participate in the medicare and medicaid programs, and that are included in medicare and medicaid payments made to the provider.

(2) A NF provider shall inform residents of the coverage and limitations of the medicare and medicaid programs. If a resident's representative is the payee for the resident's PNA account, the NF provider shall also explain the coverage and limitations to the representative.

(3) A NF provider shall not use a resident's PNA account funds to pay for costs associated with guardianship proceedings, including but not limited to the costs for assessments, medical exams, and filing fees.

(K) Items and services covered by medicare or medicaid.

(1) A NF provider shall not charge a resident's PNA account for items and services that the provider is required to furnish in order to participate in the medicare and medicaid programs.

(2) Items and services that may not be purchased with PNA account funds include, but are not limited to, the following:

(a) Nursing services; and

(b) Dietary services; and

(c) Activities programs; and

(d) Room and bed maintenance services; and

(e) Routine personal hygiene items and services required to meet the needs of the resident, including but not limited to hair hygiene supplies, comb, brush, bath soap, disinfecting soap or specialized cleansing agents when indicated to treat special skin problems or to fight infection, razor, shaving cream, toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, deodorant, incontinence care supplies, sanitary napkins and related supplies, towels, washcloths, hospital gowns, over the counter drugs, hair and nail hygiene services, bathing, and basic personal laundry; and

(f) Medically related social services; and

(g) Medical supplies such as irrigation trays, catheters, drainage bags, syringes, and needles; and

(h) Durable medical equipment; and

(i) Air conditioners, or charges to residents for the use of electricity; and

(j) Therapy or podiatry services; and

(k) Charges for telephone consultation by physicians or other personnel.

(L) Resident requests for items and services.

(1) A NF provider shall not charge a resident's PNA account for any item or service not requested by the resident, whether or not the item or service is requested by a physician.

(2) A NF provider shall not require a resident or the resident's representative to request an item or service as a condition for admission to or continued stay in the NF.

(3) When a resident requests an item or service for which a charge to the resident's PNA account will be made, the NF provider shall inform the resident that there will be a charge and the amount of the charge.

(M) Items and services that may be charged to the PNA account.

(1) If a resident clearly expresses a desire for a particular brand or item not available from the NF provider, PNA funds may be used as long as a comparable item of reasonable quality is available to the resident from the NF provider at no charge. The NF provider may charge the resident only the difference in cost between the available item and the resident's preferred item.

(2) Items and services that may be charged to a resident's PNA account include, but are not limited to, the following:

(a) Telephone; and

(b) Television or radio for personal use; and

(c) Personal comfort items, including smoking materials, notions, novelties, and confections; and

(d) Cosmetics and grooming items and services in excess of those for which payment is made under the medicaid or medicare programs, including hair cuts, permanent waves, hair coloring, and relaxing performed by barbers and beauticians; and

(e) Personal reading material; and

(f) Stationary or stamps; and

(g) Personal clothing; and

(h) Specialty laundry services such as dry cleaning, mending, or hand-washing; and

(i) Flowers or plants; and

(j) Gifts purchased on behalf of a resident; and

(k) Non-covered special care services such as privately hired nurses or nurse aides; and

(l) Social events or entertainment offered outside the scope of the NF provider's activities program; and

(m) Private rooms, except when therapeutically required for infection control or similar reasons; and

(n) Specially prepared or alternative food requested instead of food generally prepared by the NF provider; and

(o) Burial plots.

(N) Monitoring.

The CDJFS is responsible for monitoring PNA accounts. At least once a quarter, a designated CDJFS employee shall determine if a NF provider is following the provisions of this rule, and shall report any questions concerning inappropriate use or inadequate record keeping of PNA funds to ODJFS and to the Ohio department of health (ODH) for further action. Inappropriate use of PNA account funds by a payee or a NF provider does not, however, reduce the scope or duration of medicaid benefits for a medicaid recipient.

Replaces: 5101:3-3-60

Effective: 09/15/2007
R.C. 119.032 review dates: 09/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 3721.15 , 5111.11 , 5111.12
Prior Effective Dates: 7/7/80, 7/1/88 (Emer), 9/25/88, 10/1/90 (Emer), 12/31/90, 1/1/95, 7/1/96, 7/1/02

5160-3-17 Nursing facilities (NFs): payment methodology for the provision of outlier services.

(A) For the purposes of this rule:

(1) "Individual" means any person who is seeking or receiving medicaid coverage for placement in an Ohio medicaid-certified NF that is an approved outlier provider.

(2) "Individual plan (IP)" means a written description of the services to be provided to an individual, developed by an interdisciplinary team that represents the professions, disciplines or service areas that are relevant to identifying the individual's needs, as described by the comprehensive functional assessments.

(3) "Outlier services" are those clusters of services which have been determined by the Ohio department of medicaid (ODM) to require staffing ratios, certain costs, and capital investments beyond the levels otherwise addressed in Chapter 5160-3 of the Administrative Code when delivered by outlier providers to individuals who have been prior authorized for the receipt of a category of service identified as an outlier.

(4) "Outlier prior authorization committee" means a committee organized and operated by ODM that makes outlier prior authorization determinations.

(5) "Outlier provider" means any NF or discrete unit of a NF identified as such, or identified and paid as such by ODM after June 30, 1993, or approved in accordance with section 5165.153 of the Revised Code, that provides services only to individuals who have received prior authorization from the outlier prior authorization committee for the receipt of outlier services in that facility. ODM prior authorization of outlier services is contingent upon both the individual's documented need for that specific type of outlier service and evidence that the facility in which the individual is to receive services maintains the staffing ratios and ancillary and support items at levels sufficient for the provision of that type of outlier service, and has made the capital investments necessary for the provision of such care.

(B) In addition to information that must be submitted under rules 5160-3- 43.1 and 5160-3-20 of the Administrative Code, an outlier provider must submit all of the following required information:

(1) In the initial year that a NF is approved as an outlier provider, the provider must submit, no later than ninety days after the effective date of the outlier provider agreement, each of the following:

(a) The projected cost report budget for the initial year of operation; and

(b) The current calendar year capital expenditure plan, including a detailed asset listing; and

(c) The current calendar year plan for basic staffing patterns, using a format to be approved by the department, that includes the staff schedule by shift, number of staff in each position, staff position descriptions, base wage rates, and a brief explanation of contingencies that may require adjustments to these basic staffing patterns.

(2) The following information must be submitted no later than ninety days after the end of the initial three months of operation as an outlier provider:

(a) A cost report for the period of the initial three months of service; and

(b) Current IPs for residents to be served in the period for which a rate is being established.

(3) In each calendar year subsequent to the year of the initial contracted rate, the following information must be submitted by the thirty-first of March:

(a) Current IPs for residents to be served in the period for which a rate is being established; and

(b) The actual year end cost report shall be submitted within the deadline specified in accordance with rule 5160-3-20 of the Administrative Code. The current calendar year cost report budget shall be submitted by the thirty-first of March of the current calendar year, in conjunction with the previous calendar year's actual cost report; and

(c) For-profit providers shall submit a balance sheet, income statement, and statement of cash flows for the outlier facility relating to the previous calendar year's actual cost report submitted in accordance with paragraph (B)(3)(b) of this rule; and

(d) Not-for-profit providers shall submit a statement of financial position, statement of activities, and statement of cash flows for the outlier facility relating to the previous calendar year's actual cost report submitted in accordance with paragraph (B)(3)(b) of this rule; and

(e) The current calendar year capital expenditure plan, including the detailed asset listing; and

(f) The current calendar year plan for basic staffing patterns, using a format to be approved by the department, that includes the staff schedule by shift, number of staff in each position, staff position descriptions, base wage rates, and a brief explanation of contingencies that may require adjustments to these basic staffing patterns; and

(g) Approved board minutes from the legal entity holding the provider agreement and all other related legal entities for the calendar year covered by the actual cost report submitted in accordance with paragraph (B)(3)(b) of this rule.

(C) Medicaid per diem rates for outlier providers shall be based upon reasonable and allowable costs using the following methodology:

(1) There shall be five components of the per diem rate: direct care, ancillary/support services, capital, tax costs, and quality payment.

(a) The direct care per diem shall be determined in accordance with section

5165.19 of the Revised Code. The rate may be increased if deemed necessary by the department based on analysis of historical direct care costs if the provider had previously been a medicaid provider, a comparison of direct care costs and staffing ratios of facilities caring for individuals with similar needs, a comparison of payment rates paid by private insurers and/or other states, and an analysis of the impact on historical costs if there are plans to change the patient mix.

(b) The ancillary/support services per diem shall be determined in accordance with section 5165.16 of the Revised Code. The rate may be increased due to increased expenses deemed necessary by the department for treatment of individuals requiring outlier services.

(c) The capital per diem shall be determined in accordance with section 5165.17 of the Revised Code. Adjustments may be made for special high cost equipment or other capital expenditures deemed by the department to be necessary for treatment of individuals requiring outlier services.

(d) The tax costs per diem shall be determined in accordance with section 5165.21 of the Revised Code.

(e) The quality payment per diem shall be determined in accordance with section 5165.25 of the Revised Code.

(2) The total prospective rate for NFs or discrete units of NFs providing outlier services, shall be established by combining the allowable direct, ancillary/support services, capital, tax costs, and quality payment per diems determined in accordance with paragraphs (C)(1)(a) to (C)(1)(e) of this rule.

(D) Those facilities approved by the department as outlier providers shall receive rates established in accordance with this rule for individuals who have been prior authorized by the outlier prior authorization committee. The outlier providers shall receive rates established in accordance with this rule effective on the first day of the month in which prior authorized outlier services were provided, but no earlier than the first day of the month in which the approved application for an outlier provider agreement was received by the department.

(1) The department will establish the initial contracted rate no later than ninety days after the department receives all the required information. The initial contracted rate will be implemented retroactively to the initial date services were provided pursuant to the outlier provider agreement.

(2) In each year subsequent to the year of the initial contracted rate, the contracted rate will be effective for the fiscal year beginning on the first of July and ending on the thirtieth day of June of the following calendar year.

(a) If a year end cost report was submitted under paragraph (B)(3)(b) of this rule, the new rate shall be determined under paragraph (C) of this rule.

(b) If all applicable timeframes have been met, but an actual year end cost report is not available, the new rate shall be equal to the product of the rate from the prior fiscal year and the adjustment factor determined under division (B) of section 5165.15 of the Revised Code.

(c) The department will establish the contracted rate no later than the thirty-first day of July of the fiscal year for which the rate will be paid, unless the provider fails to submit all required information by the thirty-first of March.

Effective: 10/03/2014
Five Year Review (FYR) Dates: 07/01/2014 and 10/03/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02 , 5165.153
Rule Amplifies: 5165.153
Prior Effective Dates: 7/1/06

5160-3-17.1 [Rescinded] Outlier services in nursing facilities for individuals with severe maladaptive behaviors due to traumatic brain injury (NF-TBI services).

Effective: 10/03/2014
Five Year Review (FYR) Dates: 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 5164.02 , 5165.153
Rule Amplifies: 5165.01 , 5165.07 , 5165.153
Prior Effective Dates: 12/10/94, 7/1/02, 7/1/04, 7/1/05, 8/1/08

5160-3-17.2 [Rescinded] Pediatric outlier services in nursing facilities (NF-PED services).

Effective: 08/15/2014
R.C. 119.032 review dates: 05/19/2014
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5165.01 , 5165.153
Prior Effective Dates: 12/10/94, 7/1/02, 7/1/04, 7/1/05, 8/1/08

5160-3-17.3 [Rescinded] Out-of-state nursing facility (NF) services for individuals with traumatic brain injury (TBI).

Effective: 10/03/2014
Five Year Review (FYR) Dates: 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 5164.02 , 5165.153
Rule Amplifies: 5165.01 , 5165.07 , 5165.153
Prior Effective Dates: 9/3/87 (Emer.), 12/28/87, 10/1/91 (Emer.), 12/20/91, 7/1/02, 7/1/04, 8/1/08

5160-3-19 Relationship of other covered medicaid services to nursing facility (NF) services.

This rule identifies covered services generally available to medicaid recipients and describes the relationship of such services to those provided by a NF. Whenever reference is made to reimbursement of services through the "NF per diem," the rules governing such reimbursement are set forth in Chapter 5101:3-3 of the Administrative Code.

(A) Dental services.

All covered dental services provided by licensed dentists are reimbursed directly to the provider of the dental services in accordance with Chapter 5101:3-5 of the Administrative Code. Personal hygiene services provided by facility staff or contracted personnel are reimbursed through the NF per diem.

(B) Laboratory and x-ray services.

Costs incurred for the purchase and administration of tuberculin tests, and for drawing specimens and forwarding specimens to a laboratory, are reimbursable through the facility's cost report. All laboratory and x-ray procedures covered under the medicaid program are reimbursed directly to the laboratory or x-ray provider in accordance with Chapter 5101:3-11 of the Administrative Code.

(C) Medical supplier services.

Certain medical supplier services are reimbursable through the facility's cost report mechanism and others directly to the medical supply provider as follows:

(1) Items that must be reimbursed through the facility's cost report include:

(a) Costs incurred for "needed medical and program supplies" defined as those items that have a very limited life expectancy, such as, atomizers, nebulizers, bed pans, catheters, electric pads, hypodermic needles, syringes, incontinence pads, splints, and disposable ventilator circuits.

(b) Costs incurred for "needed medical equipment" (and repair of such equipment), defined as items that can stand repeated use, are primarily and customarily used to serve a medical purpose, are not useful to a person in the absence of illness or injury, and are appropriate for the use in the facility. Such medical equipment items include hospital beds, wheelchairs including custom wheelchairs and all wheelchair parts, options and accessories, and intermittent positive-pressure breathing machines, except as noted in paragraph (C)(2) of this rule.

(c) Contents of oxygen cylinders or tanks, including liquid oxygen. Oxygen producing machines (concentrators) for specific use by an individual recipient. Costs of equipment associated with oxygen administration, such as, carts, regulators/humidifiers, cannulas, masks, and demurrage.

(2) Services that are reimbursed directly to the medical supplier provider, in accordance with Chapter 5101:3-10 of the Administrative Code, include:

(a) Certain durable medical equipment items, specifically, ventilators.

(b) "Prostheses," defined as devices that replace all or part of a body organ to prevent or correct physical deformity or malfunction, such as, artificial arms or legs, electro-larynxes, and breast prostheses.

(c) "Orthoses," defined as devices that assist in correcting or strengthening a distorted part, such as, arm braces, hearing aids and batteries, abdominal binders, and corsets.

(D) Pharmaceuticals.

(1) Over-the-counter drugs including selected over-the-counter drugs set forth in paragraph (B) of rule 5101:3-9-03 of the Administrative Code and nutritional supplements are reimbursable through the NF per diem.

(2) Pharmaceuticals reimbursable directly to the pharmacy provider are subject to the limitations found in Chapter 5101:3-9 of the Administrative Code, the limitations established by the Ohio state board of pharmacy, and the following conditions:

(a) When new prescriptions are necessary following expiration of the last refill, the new prescription may be ordered only after the physician examines the patient.

(b) A copy of all records regarding prescribed drugs for all patients must be retained by the dispensing pharmacy for at least six years. A receipt for drugs delivered to a NF must be signed by the facility representative at the time of delivery and a copy retained by the pharmacy.

(E) Physical therapy, occupational therapy, speech therapy, audiology services, psychologist services, and respiratory therapy services.

For NFs, the costs incurred for physical therapy, occupational therapy, speech therapy and audiology services provided by licensed therapists or therapy assistants are reimbursed through the NF per diem. Costs incurred for the services of a licensed psychologist are reimbursable through the NF per diem. No reimbursement for psychologist services shall be made to a provider other than the NF, or a community mental health center certified by the Ohio department of mental health. Services provided by an employee of the community mental health center must be billed directly to medicaid by the community mental health center. Costs incurred for physician ordered administration of aerosol therapy that is rendered by a licensed respiratory care professional are reimbursable through the NF per diem. No reimbursement for respiratory therapy services shall be made to a provider other than the NF through the NF per diem.

(F) Physician services.

(1) A physician may be directly reimbursed for the following services provided to a resident of a NF by a physician:

(a) All covered diagnostic and treatment services in accordance with Chapter 5101:3-4 of the Administrative Code.

(b) All medically necessary physician visits in accordance with rule 5101:3-4-06 of the Administrative Code.

(c) All required physician visits as described in this rule when the services are billed in accordance with rule 5101:3-4-06 of the Administrative Code.

(i) Physician visits must be provided to a resident of a NF and must conform to the following schedule:

(a) For nursing facilities, the resident must be seen by a physician at least once every thirty days for the first ninety days after admission, and at least once every ninety days, thereafter.

(b) A physician visit is considered timely if it occurs not later than ten days after the date the visit was required.

(ii) For reimbursement of the required physician visits, the physician must:

(a) Review the resident's total program of care including medications and treatments, at each visit required by paragraph (F)(1)(c)(i) of this rule;

(b) Write, sign, and date progress notes at each visit;

(c) Sign all orders; and

(d) Personally visit (see) the patient except as provided in paragraph (F)(1)(c)(iii) of this rule.

(iii) At the option of the physician, required visits after the initial visit may be delegated in accordance with paragraph (F)(1)(c)(iv) of this rule and alternate between physician and visits by physician assistant or certified nurse practitioner.

(iv) Physician delegation of tasks.

(a) A physician may delegate tasks to a physician assistant or certified nurse practitioner as defined by Chapter 4730. of the Revised Code and Chapter 4730-1 of the Administrative Code for physician assistants, and Chapter 4723. of the Revised Code and Chapter 4723-4 of the Administrative Code for certified nurse practitioners who are in compliance with the following criteria:

(i) Are acting within the scope of practice as defined by state law; and

(ii) Are under supervision and employment of the billing physician.

(b) A physician may not delegate a task when regulations specify that the physician must perform it personally, or when delegation is prohibited by state law or the facility's own policies.

(2) Services directly reimbursable to the physician must:

(a) Be based on medical necessity, as defined in rule 5101:3-1-01 of the Administrative Code, and requested by the NF resident with the exception of the required visits defined in paragraph (F)(1)(c) of this rule; and

(b) Be documented by entries in the resident's medical records along with any symptoms and findings. Every entry must be signed and dated by the physician.

(3) Services provided in the capacity of overall medical direction are reimbursable only to a NF and may not be directly reimbursed to a physician.

(G) Podiatry services.

Covered services provided by licensed podiatrists are reimbursed directly to the authorized podiatric provider in accordance with Chapter 5101:3-7 of the Administrative Code. Payment by ODJFS is limited to one visit per month for residents in a NF setting.

(H) Transportation services.

Costs incurred by the facility for transporting residents by ambulance, ambulette, or other means of transportation are reimbursable through the NF per diem.

(I) Vision care services.

All covered vision care services, including examinations, dispensing, and the fitting of eyeglasses, are reimbursed directly to authorized vision care providers in accordance with Chapter 5101:3-6 of the Administrative Code.

Effective: 10/29/2009
R.C. 119.032 review dates: 08/13/2009 and 10/29/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.20 , 5111.262
Prior Effective Dates: 7/1/80, 3/1/84, 9/1/89, 10/1/90 (Emer.), 12/31/90, 9/30/93, 7/4/02, 2/2/06, 10/24/08, 7/31/09 (Emer.)

5160-3-20 Nursing facilities (NFs) : medicaid cost report filing, record retention, and disclosure requirements.

As a condition of participation in the Title XIX medicaid program, each NF and state operated ICF-MR shall file a cost report with the Ohio department of job and family services (ODJFS). The cost report, JFS 02524N "Medicaid Nursing Facility Cost Report" (rev. 09/2011) as found in appendix A to rule 5101:3-3-42.1 of the Administrative Code , including its supplements and attachments as specified under paragraphs (A) to (L) of this rule or other approved forms for state-operated ICFs-MR, must be filed electronically within ninety days after the end of the reporting period. Except as specified under paragraph (E) of this rule, the report shall cover a calendar year or the portion of a calendar year during which the NF or state operated ICF-MR participated in the medicaid program. In the case of a NF that has a change of operator during a calendar year, the report by the new provider shall cover the portion of the calendar year following the change of operator encompassed by the first day of participation up to and including December thirty-first, except as specified under paragraph (G) of this rule. In the case of a NF or state operated ICF-MR that begins participation after January first and ceases participation before December thirty-first of the same calendar year, the reporting period shall be the first day of participation to the last day of participation. ODJFS shall issue the appropriate software and an approved list of vendors for an electronically submitted cost report no later than sixty days prior to the initial due date of the cost report. For reporting purposes NFs shall use the chart of accounts for NFs as set forth in rule 5101:3-3-42 of the Administrative Code , or relate its chart of accounts directly to the cost report.

(A) For good cause, as deemed appropriate by ODJFS, cost reports may be submitted within fourteen days after the original due date if written approval from ODJFS is received prior to the original due date of the cost report. Requests for extensions must be in writing and explain the circumstances resulting in the need for a cost report extension.

(1) For purposes of this rule, "original due date" means each facility's cost report is due ninety days after the end of each facility's reporting period. Unless waived by ODJFS, the reporting period ends as follows:

(a) On the last day of the calendar year for the health care facility's year end cost report, except as provided in a paragraph (G)(2) of this rule; or

(b) On the last day of medicaid participation or when the facility closes in accordance with paragraph (A)(1) of rule 5101:3-3-02 of the Administrative Code; or

(c) On the last day before a change of operator; or

(d) On the last day of the new facility's or new provider's first three full calendar months of participation under the medicaid program which encompasses the first day of medicaid participation.

(2) If a facility does not submit the cost report within fourteen days after the original due date, or by the extension date granted by ODJFS or submits an incomplete or inadequate report, ODJFS shall provide immediate written notice to the facility that its provider agreement will be terminated in thirty days unless the facility submits a complete and adequate cost report within thirty days of receiving the notice.

(3) During the thirty day termination period or any additional time allowed for an appeal of the proposed termination of a provider agreement, for each day a complete and adequate cost report is not received, the provider shall be assessed a late file penalty. The late file penalty shall be determined using the prorated medicaid days paid in the late file period multiplied by the penalty. The penalty shall be two dollars per patient day adjusted each July first for inflation during the preceding twelve months as stated in division (A)(2) of section 5111.26 of the Revised Code. The late file penalty period will begin the date ODJFS issues its written notice and continue until the complete and adequate cost report is received by ODJFS or the facility is terminated from the medicaid program. The late file penalty shall be a reduction to the medicaid payment. No penalty shall be imposed during a fourteen-day extension granted by ODJFS as specified in paragraph (A) of this rule.

(B) An "Addendum for Disputed Costs" shall be an attachment to the cost report that a NF may use to set forth costs the facility believes may be disputed by ODJFS. The costs stated on the addendum schedule are to have been applied to the other schedules or attachments as instructed by the cost report and/or chart of accounts for the cost report period in question (either in the reimbursable or the nonreimbursable cost centers). Any costs reported by the facility on the addendum may be considered by ODJFS in establishing the facility's prospective rate.

(C) ODJFS shall conduct a desk review of each cost report it receives. Based on the desk review, the department shall make a preliminary determination of whether the reported costs are allowable costs. Before issuing the determination ODJFS shall notify the facility of any information on the cost report that requires further support. The facility shall provide any documentation or other information requested by ODJFS and may submit any information that it believes supports the reported costs. ODJFS shall notify each NF of any costs preliminarily determined not to be allowable and provide the reasons for the determination.

(1) The desk review is an analysis of the provider's cost report to determine its adequacy, completeness, and accuracy and reasonableness of the data contained therein. It is a process of reviewing information pertaining to the cost report without detailed verification and is designed to identify problems warranting additional review.

(2) A facility may revise the cost report within sixty days after the original due date without the revised information being considered an amended cost report.

(3) The cost report is considered accepted after the cost report has passed the desk review process.

(4) After final rates have been issued, a provider who disagrees with a desk review decision may request a rate reconsideration.

(D) Except as provided in paragraph (D)(1) of this rule and not later than three years after a provider files a cost report with ODJFS under section 5111.26 of the Revised Code, the provider may amend the cost report if the provider discovers a material error in the cost report or additional information to be included in the cost report. ODJFS shall review the amended cost report for accuracy and notify the provider of its determination.

(1) A provider may not amend a cost report if ODJFS has notified the provider that an audit of the cost report or a cost report of the provider for a subsequent cost reporting period is to be conducted under section 5111.27 of the Revised Code. The provider may, however, provide ODJFS information that affects the costs included in the cost report. Such information may not be provided after the adjudication of the final settlement of the cost report.

(2) ODJFS shall not charge interest under division (B) of section 5111.28 of the Revised Code based on any error or additional information that is not required to be reported under this paragraph. ODJFS shall review the amended cost report for accuracy and notify the provider of its determination in accordance with section 5111.27 of the Revised Code.

(E) The annual cost report submitted by state-operated facilities shall cover the twelve-month period ending June thirtieth of the preceding year, or portion thereof, if medicaid participation was less than twelve months.

(F) Cost reports submitted by county and state-operated facilities may be completed on accrual basis accounting and generally accepted accounting principles unless otherwise specified in Chapter 5101:3-3 of the Administrative Code.

(G) Three-month cost reports:

(1) Facilities and providers new to the medicaid program shall submit a cost report pursuant to paragraph (A)(1) of this rule for the period which includes the date of certification and subsequent three full calendar months of operations. The new provider of a facility that has a change of operator, on or after the effective date of this amendment shall submit a cost report within ninety days after the end of the facility's first three full calendar months after the change of operator.

(2) If a facility described in paragraph (G)(1) of this rule opens or changes operators on or after October second, the facility is not required to submit a year end cost report for that calendar year.

(H) Providers are required to identify all known related parties as set forth under paragraph (BB) of rule 5101:3-3-01 of the Administrative Code.

(I) Providers are required to identify all of the following:

(1) Each known individual, group of individuals, or organization not otherwise publicly disclosed who owns or has common ownership as set forth under paragraphs (BB) and (CC) of rule 5101:3-3-01 of the Administrative Code, in whole or in part, any mortgage, deed of trust, property or asset of the facility. When the facility or the common owner is a publicly owned and traded corporation, this information beyond basic identifying criteria is not required as part of the cost report but must be available within two weeks when requested. Publicly disclosed information must be available at the time of the audit; and

(2) Each corporate officer or director, if the provider is a corporation; and

(3) Each partner, if the provider is a partnership; and

(4) Each provider, whether participating in the medicare or medicaid program or not, which is part of an organization which is owned, or through any other device controlled, by the organization of which the provider is a part; and

(5) Any director, officer, manager, employee, individual, or organization having direct or indirect ownership or control of five per cent or more [see paragraph (H) of this rule], or who has been convicted of or pleaded guilty to a civil or criminal offense related to his involvement in programs established by Title XVIII (medicare), Title XIX (medicaid), or Title XX (social services) of the Social Security Act; and

(6) Any individual currently employed by or under contract with the provider, or related party organization, as defined under paragraph (H) of this rule, in a managerial, accounting, auditing, legal, or similar capacity who was employed by ODJFS, the Ohio department of health, the office of attorney general, the Ohio department of aging, the Ohio department of mental retardation and developmental disabilities, the Ohio department of commerce or the industrial commission of Ohio within the previous twelve months.

(J) Providers are required to provide upon request all contracts in effect during the cost report period for which the cost of the service from any individual or organization is ten thousand dollars or more in a twelve-month period; or for the services of a sole proprietor or partnership where there is no cost incurred and the imputed value of the service is ten thousand dollars or more in a twelve-month period, the audit provisions of 42 C.F.R. 420 subpart (D) (effective 12/30/82), apply to these contractors.

(1) For purposes of this rule, "contract for service" is defined as the component of a contract that details services provided exclusive of supplies and equipment. It includes any contract which details services, supplies and equipment to the extent the value of the service component is ten thousand dollars or more within a twelve-month period.

(2) For purposes of this rule, "subcontractor" is defined as any entity, including an individual or individuals, who contract with a provider to supply a service, either to the provider or directly to the beneficiary, where medicaid reimburses the provider the cost of the service. This includes organizations related to the subcontractor that have a contract with the subcontractor for which the cost or value is ten thousand dollars or more in a twelve-month period.

(K) Financial, statistical and medical records (which shall be available to ODJFS and to the U.S. department of health and human services and other federal agencies) supporting the cost reports or claims for services rendered to residents shall be retained for the greater of seven years after the cost report is filed if ODJFS issues an audit report, or six years after all appeal rights relating to the audit report are exhausted.

(1) Failure to retain the required financial, statistical, or medical records, renders the provider liable for monetary damages of the greater amount:

(a) One thousand dollars per audit; or

(b) Twenty-five per cent of the amount by which the undocumented cost increased the medicaid payments to the provider, during the fiscal year.

(2) Failure to retain the required financial, statistical, or medical records to the extent that filed cost reports are unauditable shall result in the penalty as specified in paragraph (K)(1) of this rule. Providers whose records have been found to be unauditable will be allowed sixty days to provide the necessary documentation. If, at the end of the sixty days, the required records have been provided and are determined auditable, the proposed penalty will be withdrawn. If ODJFS, after review of the documentation submitted during the sixty-day period, determines that the records are still unauditable, ODJFS shall impose the penalty as specified in paragraph (K)(1) of this rule.

(3) Refusing legal access to financial, statistical, or medical records shall result in a penalty as specified in paragraph (K)(1) of this rule for outstanding medical services until such time as the requested information is made available to ODJFS.

(4) All requested financial, statistical, and medical records supporting the cost reports or claims for services rendered to residents shall be available at a location in the state of Ohio for facilities certified for participation in the medicaid program by this state within at least sixty days after request by the state or its subcontractors. The preferred Ohio location is the facility itself, but may be a corporate office, an accountant's office, or an attorney's office elsewhere in Ohio. This requirement, however, does not preclude the state or its subcontractors from the option of conducting the audit and/or a review at the site of such records if outside of Ohio.

(L) When completing cost reports, the following guidelines shall be used to properly classify costs:

(1) All depreciable equipment valued at five hundred dollars or more per item and a useful life of at least two years or more, is to be reported in the capital cost component set forth under the Administrative Code. The costs of equipment acquired by an operating lease, including vehicles, executed before December 1, 1992, may be reported in the ancillary/support cost component for NFs if the costs were reported as administrative and general costs on the facility's cost report for the reporting period ending December 31, 1992, until the current lease term expires. The costs of any equipment leases executed before December 1, 1992 and reported as capital costs, shall continue to be reported under the capital cost component. The costs of any new leases for equipment executed on or after December 1, 1992, shall be reported under the capital costs component. Operating lease costs for equipment, which result from extended leases under the provision of a lease option negotiated on or after December 1, 1992, shall be reported under the capital cost component.

(2) Except for employers' share of payroll taxes, workers compensation, employee fringe benefits, and home office costs, allocation of commonly shared expenses across cost centers shall not be allowed. Wages and benefits for staff including related parties who perform duties directly related to functions performed in more than one cost center which would be expended under separate cost centers if performed by separate staff may be expended to separate cost centers based upon documented hours worked, provided the facility maintains adequate documentation of hours worked in each cost center. For example, the salary of an aide who is assigned to bathing and dressing chores in the early hours but works in the kitchen as a dietary aide for the remainder of the shift may be expended to separate cost centers provided the facility maintains adequate documentation of hours worked in each cost center.

(3) The costs of resident transport vehicles are reported under the capital cost component. Maintenance and repairs of these vehicles is reported under the ancillary/support cost component for NFs .

Effective: 01/10/2013
R.C. 119.032 review dates: 03/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.26
Rule Amplifies: 5111.26 , 5111.261 , 5111.27 , 5111.28
Prior Effective Dates: 12/30/77, 8/3/79, 7/1/80, 1/19/84, 3/29/85, 12/31/87
(Emer.), 3/30/88, 7/1/88, 12/20/88 (Emer.), 3/18/89, 12/28/89 (Emer.), 3/22/90, 10/1/90 (Emer.), 12/20/91 (Emer.), 3/19/92, 6/30/92, 12/1/92, 6/26/93, 12/30/93 (Emer.), 3/18/94, 12/31/94, 12/28/95, 3/20/97 (Emer.), 5/22/97, 3/31/98 (Emer.), 12/17/98, 9/12/03, 7/1/05, 2/9/06, 10/24/08, 2/15/10, 3/19/12

5160-3-22 Rate recalculations, interest on overpayments, penalties, repayment of overpayments, and deposit of repayment of overpayments for nursing facilities (NFs).

(A) If the provider properly amends its cost report under rule 5101:3-3-20 of the Administrative Code, the Ohio department of job and family services (ODJFS) makes a finding based on an audit under section 5111.27 of the Revised Code, or ODJFS makes a finding based on an exception review of resident assessment information conducted under section 5111.27 of the Revised Code after the effective date of the rate for direct care costs that is based on the assessment information any of which results in a determination that the provider has received a higher rate than it was entitled to receive, ODJFS shall recalculate the provider's rate using the revised information. ODJFS shall apply the recalculated rate to the periods when the provider received the incorrect rate to determine the amount of the overpayment. The provider shall refund the amount of the overpayment. In addition to requiring a refund under this rule, ODJFS may charge the provider interest at the applicable rate specified in this rule from the time the overpayment was made.

(1) If the overpayment resulted from costs reported for calendar year 1993, the interest shall be no greater than one and one-half times the average bank prime rate.

(2) If the overpayment resulted from costs reported for subsequent calendar years:

(a) The interest shall be no greater than two times the average bank prime rate if the overpayment was equal to or less than one per cent of the total medicaid payments to the provider for the fiscal year for which the incorrect information was used to establish a rate.

(b) The interest shall be no greater than two and one-half times the average bank prime rate if the overpayment was greater than one per cent of the total medicaid payments to the provider for the fiscal year for which the incorrect information was used to establish a rate.

(3) ODJFS shall determine the average bank prime rate using statistical release H.15, "Selected Interest Rates," a weekly publication of the federal reserve board available at http://www.federalreserve.gov/releases/H15/, or any successor publication. If statistical release H.15, or its successor ceases to contain the bank prime rate information or ceases to be published, ODJFS shall request a written statement of the average bank prime rate from the federal reserve bank of Cleveland or the federal reserve board.

(B) ODJFS also may impose the following penalties and fines:

(1) If a provider does not furnish invoices or other documentation that ODJFS requests during an audit within sixty days after the request, no more than the greater of one thousand dollars per audit or twenty-five per cent of the cumulative amount by which the costs for which documentation was not furnished increased the total medicaid payments to the provider during the fiscal year for which the costs were used to establish a rate;

(2) If an owner or operator fails to provide notice of facility closure, voluntary withdrawal or voluntary termination of participation in the medicaid program, or change of operator as required by the Revised Code, no more than the current average bank prime rate plus four per cent of the last two monthly payments.

(3) ODJFS shall fine the provider of a nursing facility if the report of an audit conducted under division (B) of section 5111.27 of the Revised Code regarding a cost report for the nursing facility includes either of the following:

(a) Adverse findings that exceed three per cent of the total amount of medicaid-reimbursable costs reported in the cost report;

(b) Adverse findings that exceed twenty per cent of medicaid-reimbursable costs for a particular cost center reported in the cost report.

(4) A fine issued under paragraph (B)(3) of this rule shall equal the greatest of the following:

(a) If the adverse findings exceed three per cent but do not exceed ten per cent of the total amount of medicaid-reimbursable costs reported in the cost report, the greater of three per cent of those reported costs or ten thousand dollars;

(b) If the adverse findings exceed ten per cent but do not exceed twenty per cent of the total amount of medicaid-reimbursable costs reported in the cost report, the greater of six per cent of those reported costs or twenty-five thousand dollars;

(c) If the adverse findings exceed twenty per cent of the total amount of medicaid-reimbursable costs reported in the cost report, the greater of ten per cent of those reported costs or fifty thousand dollars;

(d) If the adverse findings exceed twenty per cent but do not exceed twenty-five per cent of medicaid-reimbursable costs for a particular cost center reported in the cost report, the greater of three per cent of the total amount of medicaid-reimbursable costs reported in the cost report or ten thousand dollars;

(e) If the adverse findings exceed twenty-five per cent but do not exceed thirty per cent of medicaid-reimbursable costs for a particular cost center reported in the cost report, the greater of six per cent of the total amount of medicaid-reimbursable costs reported in the cost report or twenty-five thousand dollars;

(f) If the adverse findings exceed thirty per cent of medicaid-reimbursable costs for a particular cost center reported in the cost report, the greater of ten per cent of the total amount of medicaid-reimbursable costs reported in the cost report or fifty thousand dollars.

(5) The department may not collect a fine issued under paragraph (B)(3) of this rule until all appeal rights relating to the audit report that is the basis for the fine are exhausted.

(C) If the provider continues to participate in the medicaid program, ODJFS shall deduct any amount that the provider is required to refund under this rule, and the amount of any interest charged or penalty imposed under this rule, from the next available payment from ODJFS to the provider. ODJFS and the provider may enter into an agreement under which the amount, together with interest, is deducted in installments from payments from ODJFS to the provider.

(D) Fines issued under paragraph (B)(3) of this rule and paid shall be deposited into the health care services administration fund created under section 5111.94 of the Revised Code. ODJFS shall transmit all other refunds and penalties issued under this rule to the treasurer of state for deposit in the general revenue fund.

Effective: 01/10/2013
R.C. 119.032 review dates: 03/01/2017
Promulgated Under: 119.03
Statutory Authority: 511.02
Rule Amplifies: 5111.27 , 5111.271 , 5111.28
Prior Effective Dates: 6/30/94 (Emer.), 11/1/94, 7/4/02, 2/2/06, 12/31/06, 3/19/12

5160-3-24 Prospective rate reconsideration for nursing facilities (NFs) for possible calculation errors.

(A) A facility, group, or association may request a reconsideration of a prospective NF rate on the basis of a possible error in the calculation of the rate as follows;

(1) A request for reconsideration of a prospective rate on the basis of a possible error in the calculation of the rate shall be filed with the Ohio department of job and family services (ODJFS) no more than thirty days after the later of the initial payment of the rate or the receipt of the rate-setting calculation.

(2) The request for a reconsideration of a prospective rate on the basis of a possible error in the calculation of the rate shall be filed in accordance with the following procedures:

(a) The request for rate reconsideration shall be in writing; and

(b) The request shall be addressed to "Ohio Department of Jobs and Family Services, Bureau of Long Term Care Facilities, Reimbursement Section, 30 East Broad Street, 33rd Floor, Columbus, Ohio 43215-3414"; and

(c) The request shall indicate that it is a request for rate reconsideration due to a possible error in the calculation of the rate; and

(d) The request shall include a detailed explanation of the possible error and the proposed corrected calculation; and

(e) The request shall include references to the relevant sections of the Revised Code and/or paragraphs of the Administrative Code as appropriate.

(3) ODJFS shall respond in writing within sixty days of receiving each written request for reconsideration of a prospective rate due to a possible error in the calculation of the rate. If ODJFS requests-additional information to determine whether a rate adjustment is warranted, the NF shall respond in writing and shall provide additional supporting documentation no more than thirty days after the receipt of the request for additional information. ODJFS shall respond in writing within sixty days of receiving the additional information to the request for reconsideration of a prospective rate due to a possible error in the calculation of the rate.

(4) If a rate adjustment is warranted as the result of a reconsideration of a prospective rate due to a possible error in calculation, the adjustment shall be implemented retroactively to the initial service date for which the rate is effective.

(B) ODJFS's decision at the conclusion of the rate reconsideration process shall not be subject to any administrative proceedings under Chapter 119. or any other provision of the Revised Code.

Effective: 07/01/2006
R.C. 119.032 review dates: 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.29
Rule Amplifies: 5111.29

5160-3-30.1 Appeal of the franchise permit fee (FPF) determination and re-determination.

(A) When submitting an appeal of a FPF determination or re-determination for a nursing home or hospital long term care unit in accordance with section 3721.55 of the Revised Code, a facility operator shall follow these procedures:

(1) The appeal shall be in writing and must be received by ODJFS not later than fifteen days after the date on which the FPF assessment notice was mailed.

(2) The appeal shall be submitted to ODJFS and addressed to the organization listed in the instructions that are sent with the assessment notice. If this address is invalid, the facility shall contact the bureau of long term care services and supports (BLTCSS).

(3) The appeal shall indicate that it is an appeal of the FPF due to a possible material error in determining the amount of the fee.

(4) The appeal shall include a detailed explanation of the possible material error and the proposed correction of the amount of the fee.

(5) The appeal shall include references to the relevant sections of the Revised Code or rules of the Administrative Code that support the position of the appeal.

(B) If a representative of a facility is unable to attend the hearing, the representative shall request a teleconference hearing at least five days prior to the scheduled hearing.

Effective: 01/10/2013
R.C. 119.032 review dates: 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 3721.58 , 5112.39
Rule Amplifies: 3721.50 , 3721.51 , 3721.531 , 3721.532 , 3721.55
Prior Effective Dates: 9/30/93 (Emer.), 1/1/94, 1/12/96, 9/30/01, 2/11/02, 9/30/02, 9/30/03 (Emer.), 02/11/03, 4/12/04, 7/1/05, 12/30/05, 4/30/07, 10/15/10, 3/19/12

5160-3-30.4 Procedure for terminating the franchise permit fee (FPF) for nursing facilities (NFs), nursing homes (NHs), and long term care hospital beds.

(A) Definitions.

"Effective FPF termination date" (EFTD) means the date on which the centers for medicare and medicaid services (CMS) determines that the FPF does not qualify for federal financial participation.

(B) Determination of the FPF as an impermissible health care related tax.

If CMS determines that the FPF is an impermissible health care related tax, the Ohio department of job and family services (ODJFS) shall take all necessary actions to cease implementation of the FPF program, pursuant to section 3721.51 of the Revised Code.

(C) Notification.

ODJFS shall notify each facility previously assessed the FPF of the effective date of the termination of the FPF program, and what impact this change will have on the facility.

(D) Reconciliation procedure.

ODJFS shall conduct an accounting of the funds paid to or collected from each facility as a result of the FPF program and shall do all of the following:

(1) Reconcile FPFs paid by NFs, NHs, and hospitals.

(a) The annual assessment of the FPF shall be prorated on a daily basis.

(b) FPF assessments for the days preceding the EFTD shall remain due and payable.

(c) Collection shall be pursued in accordance with sections 3721.54 and 3721.57 of the Revised Code.

(d) FPF assessments issued for days on and after the EFTD shall be rescinded.

(i) ODJFS shall issue refunds to NHs and hospitals for any FPF remittances representing payment for daily fees on or beyond the EFTD, unless a NF or skilled nursing facility/nursing facility (SNF/NF) has already received medicaid payment for service dates described in paragraph (D)(3) of this rule.

(ii) The source of the refunds shall be the funds established by the FPF assessments as set forth in sections 3721.56 and 3721.561 of the Revised Code, if necessary, to each NH and hospital assessed the FPF.

(2) Adjust NF rates set by ODJFS that include reimbursement for FPF assessment payments by medicaid certified NFs and SNF/NFs. ODJFS shall adjust the per diem rate of a NF to remove any FPF reimbursement-related amount retroactively and/or prospectively from the rate for dates of service on and after EFTD.

(3) Reconcile paid claims for service dates on and following the EFTD with rates adjusted according to paragraph (D)(2) of this rule.

(a) Active providers.

(i) If claims have already been submitted to ODJFS and processed for dates of service on or after the EFTD, ODJFS shall offset the amount of overpayment received with the amount of refund due from paragraph (D)(1) of this rule.

(ii) If the offset results in amounts owed to the facility, refunds shall be issued.

(iii) If the offset results in amounts owed to ODJFS, the amount payable may be collected via offsets of future payments.

(b) Inactive providers.

(i) If claims have already been submitted to ODJFS and processed for dates of service on or after the EFTD by a NF or SNF/NF provider that no longer participates in the medicaid program, ODJFS shall offset the amount of overpayment received with the amount of refund due from paragraph (D)(1) of this rule.

(ii) If the offset results in amounts owed to the facility, refunds shall be issued if the provider has furnished an adequate forwarding address.

(iii) If the offset results in amounts owed to ODJFS, the amount payable may be collected via direct payment from the provider.

(iv) Failure to provide payment may result in certification to the attorney general for collection as set forth in section 3721.57 of the Revised Code.

Effective: 01/10/2013
R.C. 119.032 review dates: 10/01/2015
Promulgated Under: 119.03
Statutory Authority: 3721.58 , 5111.02 , 5112.39
Rule Amplifies: 3721.50 , 3721.51 , 3721.511 , 3721.512 , 3721.513 , 3721.52 , 3721.53 , 3721.54 , 3721.541 , 3721.55 , 3721.56 , 3721.57 , 3721.58
Prior Effective Dates: 9/30/93 (Emer.), 1/1/94, 9/30/01, 2/14/02, 4/12/04, 12/30/05, 10/15/10

5160-3-32 Debt estimation methodology for change of operator, facility closure, voluntary termination, involuntary termination, or voluntary withdrawal for nursing facilities (NFs).

(A) The Ohio department of job and family services (ODJFS) shall use the debt estimation methodology set forth in this rule to estimate the exiting operator's actual and potential debts to ODJFS and the United States centers for medicare and medicaid services (CMS) under the medicaid program.

(B) ODJFS shall total the value of all of the following that are determined applicable in calculating the debt estimate:

(1) Overpayments determined due to ODJFS pursuant to section 5111.27 of the Revised Code, including the following:

(a) Overpayments owed to ODJFS for adjudicated final fiscal audit periods.

(b) Overpayments identified in proposed adjudication orders that have been issued but not adjudicated.

(c) Overpayment amounts for any outstanding periods where a final fiscal audit has not yet been issued. Such amounts are estimated by generating preliminary reports of amounts owed by the exiting operator for the applicable periods.

(2) Monies owed to ODJFS and CMS resulting from penalties authorized by federal and state law, including but not limited to the following:

(a) Civil monetary penalties (CMPs) imposed pursuant to 42 C.F.R. 488.430 .

(b) Penalties assessed pursuant to section 5111.28 of the Revised Code for lack of proper notice of a change of operator, facility closure, voluntary termination, or voluntary withdrawal from the medicaid program.

(c) Late cost report filing penalties assessed pursuant to rule 5101:3-3-20 of the Administrative Code.

(d) Penalties assessed pursuant to rule 5101:3-3-22 of the Administrative Code when a provider fails to furnish invoices or other documentation that ODJFS requests during an audit.

(3) Interest monies owed to ODJFS pursuant to section 5111.28 of the Revised Code, and to CMS pursuant to 42 C.F.R. 488.442 .

(4) Monies owed ODJFS and CMS pursuant to sections 5111.68 and 5111.685 of the Revised Code, including a final fiscal audit for the last fiscal year or portion thereof that the exiting operator participated in the medicaid program.

(5) Franchise permit fee (FPF) owed to ODJFS pursuant to section 3721.53 of the Revised Code. FPF owed to ODJFS shall include unpaid FPF for the following:

(a) Amounts due for periods assessed or to be assessed but for which payment is not yet required pursuant to section 3721.53 of the Revised Code.

(b) Amounts due that are certified to the Ohio attorney general's office for collection, including penalties assessed pursuant to section 3721.54 of the Revised Code for failure to pay the full amount when due.

(6) Monies owed due to a credit balance.

(7) Monies owed pursuant to successor liability or assumption of liability agreements the exiting operator entered into.

(8) Other amounts ODJFS determines are applicable.

(C) The sum of the amounts determined owed, or estimated to be owed, to ODJFS and CMS pursuant to paragraphs (B)(1) to (B)(9) of this rule shall be the total estimated debt.

(D) ODJFS may release a portion of funds withheld pursuant to division (A) of section 5111.681 of the Revised Code if the funds withheld are materially greater than the debt calculated by the department in the initial debt summary report issued pursuant to section 5111.685 of the Revised Code.

Effective: 01/10/2013
R.C. 119.032 review dates: 03/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.689
Rule Amplifies: 3721.53 , 3721.54 , 5111.27 , 5111.28 , 5111.68 , 5111.681 , 5111.683 , 5111.685
Prior Effective Dates: 8/31/10 (Emer.), 11/29/10, 3/19/12

5160-3-32.1 Debt estimate and debt summary report procedure for change of operator, facility closure, voluntary termination, involuntary termination, or voluntary withdrawal for nursing facilities (NFs).

(A) Debt estimate.

For the purposes of division (C) of section 5111.68 of the Revised Code, the debt estimate is considered provided by the Ohio department of job and family services (ODJFS) on the date of mailing or date of personal service.

(B) Initial debt summary report.

(1) Whenever ODJFS issues an initial debt summary report pursuant to section 5111.685 of the Revised Code, ODJFS shall give notice to the affected party informing the affected party of the affected party's right to request a review. Notice shall be given by registered mail, return receipt requested, and shall include:

(a) A statement informing the affected party that the affected party is entitled to request a review of the initial debt summary report.

(b) A statement informing the affected party that if a request for review of the initial debt summary report is not submitted on or before thirty days after the mailing of the initial debt summary report, the initial debt summary report becomes the final debt summary report thirty-one days after the mailing of the initial debt summary report, and that the affected party may request, in accordance with Chapter 119. of the Revised Code, an adjudication hearing regarding a finding in the final debt summary report that pertains to an audit or alleged overpayment made under the medicaid program to the exiting operator. The adjudication shall be consolidated with any other uncompleted adjudication that concerns a matter addressed in the final debt summary report.

(2) ODJFS shall also mail a copy of the notice to the affected party's attorney or other representative of record. To qualify as an attorney or representative of record, the affected party or the attorney or representative must notify ODJFS, in writing, that the attorney or representative is to be designated the attorney or representative of record for purposes of receiving notice of an initial debt summary report. The notification must include the address where ODJFS should mail the notice to the attorney or representative of record. The mailing of notice to the affected party's attorney or representative is not deemed to perfect service of the notice. Failure to mail a copy of the notice to the attorney or representative of record will not result in failure of otherwise perfected service upon the affected party. In those instances where an affected party is a corporation doing business in Ohio or is incorporated in Ohio, the mailing of notice to the corporation's statutory agent pursuant to sections 1701.07 and 1703.19 of the Revised Code will perfect service.

(3) When any notice of an initial debt summary report is sent by registered mail pursuant to this rule is returned because the affected party fails to claim the notice, ODJFS shall send the notice by ordinary mail to the affected party at the affected party's last known address and shall obtain a certificate of mailing. Service by ordinary mail is complete when the certificate of mailing is obtained unless the notice is returned showing failure of delivery.

(4) If any notice of an initial debt summary report is sent by registered or ordinary mail is returned for failure of delivery, ODJFS shall make personal delivery of the notice by an employee or agent of ODJFS. An employee or agent of ODJFS may make personal delivery of the notice upon a party at any time.

(5) Refusal of delivery of an initial debt summary report by personal service or by mail is not failure of delivery and service is deemed to be complete at the time of personal refusal or at the time of receipt by ODJFS of the refused mail as demonstrated by the ODJFS time and date stamp. Failure of delivery occurs only when a mailed notice is returned by the postal authorities marked undeliverable, address or addressee unknown, or forwarding address unknown or expired.

(6) Any request for a review made as the result of notice of an initial debt summary report issued pursuant to paragraph (B) of this rule must be made in writing and mailed or delivered to the ODJFS office and address identified in the initial debt summary report within thirty calendar days of the following, as applicable:

(a) The time of mailing the notice if notice is given pursuant to paragraph (B)(1) of this rule;

(b) The date that service is complete if notice is given pursuant to paragraph (B)(3) or (B)(5) of this rule;

(c) The date of personal service.

(7) If a request for review is mailed to the ODJFS office and address identified in the initial debt summary report, the request is deemed to have been made as follows:

(a) If the request is mailed by certified mail, as of the date stamped by the U.S. postal service on its receipt form (PS form 3800 or any future equivalent postal service form).

(b) If the request is mailed by regular U.S. mail, as of the date of the postmark appearing upon the envelope containing the request.

(c) If the request is mailed by regular U.S. mail and the postmark is illegible or fails to appear on the envelope, as of the date of its receipt by ODJFS office identified in the initial debt summary report as evidenced by that office's time stamp.

(8) If a request for review is made by facsimile transmission or by electronic mail to the office identified in the initial debt summary report, the request is deemed to have been made as of the date of its receipt as evidenced by the receipt date generated by the facsimile transmission or the date of receipt shown in the source code of the electronic mail received by the office identified in the initial debt summary report.

(9) If a request for review is mailed, personally delivered, made by facsimile transmission, or made by electronic mail to a party or address other than the proper office identified in the initial debt summary report, the request is deemed to have been made as of the date of its receipt by the office identified in the initial debt summary report as evidenced by that office's time stamp.

(10) If a request for review is personally delivered to the office identified in the initial debt summary report, the request is deemed to have been made as of the date of its receipt as evidenced by that office's time stamp.

(11) All requests for review must clearly identify both the affected party involved and the initial debt summary report that is being contested.

(C) Revised debt summary report.

(1) Whenever ODJFS issues a revised debt summary report pursuant to section 5111.685 of the Revised Code, ODJFS shall give notice to the affected party informing the affected party of the affected party's right to submit additional information. Notice shall be given by registered mail, return receipt requested, and shall include:

(a) A statement informing the affected party that the affected party is entitled to submit additional information.

(b) A statement informing the affected party that if additional information is not submitted on or before thirty days after the mailing of the revised debt summary report, the revised debt summary report becomes the final debt summary report thirty-one days after the mailing of the revised debt summary report, and that the affected party may request, in accordance with Chapter 119. of the Revised Code, an adjudication hearing regarding a finding in the final debt summary report that pertains to an audit or alleged overpayment made under the medicaid program to the exiting operator. The adjudication shall be consolidated with any other uncompleted adjudication that concerns a matter addressed in the final debt summary report.

(2) ODJFS shall also mail a copy of the notice to the affected party's attorney or other representative of record. To qualify as an attorney or representative of record, the affected party or the attorney or representative must notify ODJFS, in writing, that the attorney or representative is to be designated the attorney or representative of record for purposes of receiving notice of a revised debt summary report. The notification must include the address where ODJFS should mail the notice to the attorney or representative of record. The mailing of notice to the affected party's attorney or representative is not deemed to perfect service of the notice. Failure to mail a copy of the notice to the attorney or representative of record will not result in failure of otherwise perfected service upon the affected party. In those instances where an affected party is a corporation doing business in Ohio or is incorporated in Ohio, the mailing of notice to the corporation's statutory agent pursuant to sections 1701.07 and 1703.19 of the Revised Code will perfect service.

(3) When any notice of a revised debt summary report is sent by registered mail pursuant to this rule is returned because the affected party fails to claim the notice, ODJFS shall send the notice by ordinary mail to the affected party at the affected party's last known address and shall obtain a certificate of mailing. Service by ordinary mail is complete when the certificate of mailing is obtained unless the notice is returned showing failure of delivery.

(4) If any notice of a revised debt summary report sent by registered or ordinary mail is returned for failure of delivery, ODJFS shall make personal delivery of the notice by an employee or agent of ODJFS. An employee or agent of ODJFS may make personal delivery of the notice upon a party at any time.

(5) Refusal of delivery of a revised debt summary report by personal service or by mail is not failure of delivery and service is deemed to be complete at the time of personal refusal or at the time of receipt by ODJFS of the refused mail as demonstrated by the ODJFS time and date stamp. Failure of delivery occurs only when a mailed notice is returned by the postal authorities marked undeliverable, address or addressee unknown, or forwarding address unknown or expired.

(6) Any submission of additional information made as the result of notice of a revised debt summary report issued pursuant to paragraph (C) of this rule must be made in writing and mailed or delivered to the ODJFS office and address identified in the revised debt summary report within thirty calendar days of the following, as applicable:

(a) The time of mailing the notice if notice is given pursuant to paragraph (C)(1) of this rule;

(b) The date that service is complete if notice is given pursuant to paragraph (C)(3) or (C)(5) of this rule;

(c) The date of personal service.

(7) If a submission of additional information is mailed to the ODJFS office and address identified in the revised debt summary report, the request is deemed to have been made as follows:

(a) If the submission of additional information is mailed by certified mail, as of the date stamped by the U.S. postal service on its receipt form (PS form 3800 or any future equivalent postal service form).

(b) If the submission of additional information is mailed by regular U.S. mail, as of the date of the postmark appearing upon the envelope containing the request.

(c) If the submission of additional information is mailed by regular U.S. mail and the postmark is illegible or fails to appear on the envelope, as of the date of its receipt by ODJFS office identified in the revised debt summary report as evidenced by that office's time stamp.

(8) If a submission of additional information is made by facsimile transmission or by electronic mail to the office identified in the revised debt summary report, the submission is deemed to have been made as of the date of its receipt as evidenced by the receipt date generated by the facsimile transmission or the date of receipt shown in the source code of the electronic mail received by the office identified in the revised debt summary report.

(9) If a submission of additional information is mailed, personally delivered, made by facsimile transmission, or made by electronic mail to a party or address other than the proper office identified in the revised debt summary report, the request is deemed to have been made as of the date of its receipt by the office identified in the revised debt summary report as evidenced by that office's time stamp.

(10) If a submission of additional information is personally delivered to the office identified in the revised debt summary report, the request is deemed to have been made as of the date of its receipt as evidenced by that office's time stamp.

(11) All submissions of additional information must clearly identify both the affected party involved and the revised debt summary report that is being contested.

(D) Final debt summary report.

Rule 5101:6-50-03 of the Administrative Code shall apply if a party timely submits a request for review, and additional information in response to a revised debt summary report, and ODJFS issues a final debt summary report pursuant to section 5111.685 of the Revised Code. An adjudication on a final debt summary report shall be conducted only with respect to findings in the final debt summary report that pertain to an audit or alleged overpayment made under the medicaid program to the exiting operator. The adjudication shall be consolidated with any other uncompleted adjudication that concerns a matter addressed in the final debt summary report.

(E) Computation of time deadlines.

Section 1.14 of the Revised Code controls the computing of time deadlines imposed by this rule. The time within which an act is required by law to be completed is computed by excluding the first day and including the last day. When the last day falls on a Saturday, Sunday, or legal holiday, the act may be completed on the next succeeding day that is not a Saturday, Sunday, or legal holiday. When the last day to perform an act that is required by law is to be performed in a public office and that public office is closed to the public for the entire day, the act may be performed on the next succeeding day that is not a Saturday, Sunday, or legal holiday.

Effective: 01/10/2013
R.C. 119.032 review dates: 03/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.689
Rule Amplifies: 5111.68 , 5111.685
Prior Effective Dates: 11/29/10, 3/19/12

5160-3-32.2 Successor liability agreements for operators of nursing facilities (NFs).

(A) Successor liability agreements entered into pursuant to section 5111.681 of the Revised Code are subject to approval by the Ohio department of job and family services (ODJFS).

(B) Successor liability agreements must be signed by the exiting operator, ODJFS, and the entity assuming liability pursuant to section 5111.681 of the Revised Code.

Effective: 01/10/2013
R.C. 119.032 review dates: 11/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.689
Rule Amplifies: 5111.681
Prior Effective Dates: 11/29/10

5160-3-39 Payment and adjustment process for nursing facilities (NFs).

(A) Forms.

For dates of services preceding July 1, 2005, NFs shall submit the form "Nursing Facility Payment and Adjustment Authorization" (JFS 09400, rev. 10/2012) directly to the Ohio department of job and family services (ODJFS) for the reimbursement of services.

The county department of job and family services (CDJFS) and NFsshall use the "Facility/CDJFS Transmittal" (JFS 09401, rev. 4/2011) form to exchange information necessary to complete the billing process for payment.

(B) Notification of admission.

The facility shall notify the CDJFS using the JFS 09401 form within five business days of admission of a new resident who is medicaid eligible or who has an application for medicaid that is pending even if care may initially be covered under a medicare benefit.

(C) Notification of death.

The NF shall notify the CDJFS of the death of a medicaid resident by completing the JFS 09401 and forwarding it to the CDJFS within five business days following the death of the resident. The CDJFS shall terminate medicaid eligibility within ten days after the receipt of the JFS 09401.

For dates of service preceding July 1, 2005, the CDJFS shall stop vendor payment within ten days after the receipt of the JFS 09401.

(1) The CDJFS shall complete and return the JFS 09401, when appropriate, to the NF within ten days of the receipt of the JFS 09401 for any required payment adjustment.

(2) The NF shall complete the JFS 09400, when appropriate (e.g., final payment adjustment), within thirty days of the receipt of the JFS 09401 and submit it to the address listed on the bottom of form JFS 09400.

(D) Notification of discharge.

Discharge has the same meaning as defined in rule 5101:3-3-16.4 of the Administrative Code. The NF shall notify the CDJFS within five business days of the discharge of a medicaid eligible resident by completing the JFS 09401 identifying the type of discharge, and forwarding the JFS 09401 to the CDJFS. The CDJFS shall adjust medicaid eligibility within ten days after the receipt of the JFS 09401.

For dates of service preceding July 1, 2005, the CDJFS shall stop vendor payment within ten days after the receipt of the JFS 09401.

(1) The CDJFS shall complete and return the JFS 09401, when appropriate, to the NF within ten days after the receipt of the JFS 09401 for any required payment adjustment.

(2) The NF shall complete the JFS 09400, when appropriate (e.g., final payment adjustment), within thirty days of the receipt of the JFS 09401 and submit to the address listed on the bottom of form JFS 09400.

(E) Notification of hospice enrollment.

If a NF resident on medicaid vendor payment elects to receive medicaid hospice services in accordance with rule 5101:3-56-03 of the Administrative Code, the NF shall notify the CDJFS by completing the JFS 09401 and forwarding it to the CDJFS within five business days of receiving notice from the hospice agency that a resident elected hospice services. The CDJFS shall adjust medicaid eligibility within ten days after receipt of the JFS 09401 for the resident enrolled in hospice.

For dates of service preceding July 1, 2005, the CDJFS shall stop vendor payment within ten days after the receipt of the JFS 09401.

(1) The CDJFS shall complete and return the JFS 09401, when appropriate (e.g., final payment adjustment), to the NF within ten days of the receipt of the JFS 09401 for any required payment adjustment.

(2) The NF shall complete the JFS 09400, when appropriate, within thirty days of the receipt of the JFS 09401 and submit it to the address on the bottom of form JFS 09400.

Effective: 01/10/2013
R.C. 119.032 review dates: 10/16/2012 and 01/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01
Prior Effective Dates: 12/1/94, 5/1/96, 7/1/97, 7/1/98, 9/1/02, 7/1/05

5160-3-39.1 Claim submission for nursing facilities (NFs).

(A) Claim requirements

(1) For dates of services commencing July 1, 2005, all nursing facilities (NFs) shall submit claims electronically for medicaid reimbursement for nursing facility services in compliance with electronic data interchange (EDI) standards established under the Health Insurance Portability and Accountability Act of 1996 using the ANSI 837 health care claim institutional (837I) transaction.

(2) Ohio Medicaid ANSI 837I claim specifications for nursing facilities are provided in the ohio department of job and family services (ODJFS) 837I companion guide (available on www.hipaa.oh.gov/odjfs).

(3) Claims must use the UB-92 national uniform billing data element specifications as developed by the national uniform billing committee(available on http://www.nubc.org/), to obtain and indicate codes in the ANSI 837I regarding provider information, bill type, demographic information, patient status, condition codes, occurrence codes, value codes, revenue codes and other codes as required in the ODJFS companion guide.

(4) Claims must use, if required by the claim format, "The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) 2005 Edition" (available on http://www.cdc.gov/nchs/icd9.htm#RTF) to specify the diagnosis or nature of the injury of the resident related to the services provided as specified in rule 5101:3-1-19.2 of the Administrative Code.

(5) For dates of service preceding July 1, 2005, NFs shall continue to use the JFS 09400 rev. 12/2001 nursing facility payment and adjustment authorization.

(6) The following shall apply for dates of service beginning July 1, 2005 and ending November 30, 2005, for providers who are unable to comply with paragraph (A)(1) of this rule:

(a) The monthly payment shall be calculated as follows:

(i) The NF's average fiscal year (FY) 2005 vendor payment will be calculated.

(ii) The amount calculated in paragraph (A)(6)(a)(i) of this rule will be reduced by ten per cent.

(b) For each month, the provider shall request the monthly payment calculated in paragraph (6)(a) of this rule, through the gross adjustment process.

(i) A written request must be received by ODJFS no later than noon on the first Friday of each month.

(c) For dates of service beginning July 1, 2005, and ending November 30, 2005, the provider is still required to submit claims on the 837I as required in paragraph (A)(1) of this rule.

(d) Each gross adjustment payment will be reversed the following month.

(e) Effective for dates of service on or after December 1, 2005, providers shall not be reimbursed for services unless claims for services are submitted on the 837I as required in paragraph (A)(1) of this rule.

(B) Criteria for claims submission:

(1) A provider submitting a claim for payment, either directly as a trading partner as defined in rule 5101:3-1-20.1 of the Administrative Code or through another trading partner, shall be a Medicaid provider in an active enrollment status and eligible to provide nursing facility services for all dates within the claim span.

(2) The claim must meet the requirements of the current version of the claim transaction required in paragraph (A) of this rule and as specified in the ODJFS 837I companion guide.

(3) A single claim shall include services provided by a single provider to a single recipient within a single calendar month and shall not cross a calendar month.

(4) Circumstances under which a partial month of services may be billed:

(a) Admission claims where the resident was admitted after the first of the month.

(b) Discharge claims where the resident was discharged, transferred or died during the month.

(c) The resident's coverage switches between medicare part A or medicare part C and medicaid within the month.

(C) Claim filing timing requirements:

(1) Claims must be received by ODJFS within three hundred sixty-five days of the actual date the service was provided, unless the provisions in paragraph (C)(2) or (C)(3) of this rule apply or the claim will be denied. Initial claims received beyond the three hundred sixty-five day time limit shall not be processed for payment by ODJFS. The "date of receipt," for purposes of this rule, is the date ODJFS receives a claim and assigns a transaction control number (TCN).

(2) If the claim submittal is delayed due to the pendency of either an administrative hearing decision by ODJFS or an eligibility determination by a county department of job and family services (CDJFS), it will be adjudicated if the claim is received within one hundred eighty days of the date of the administrative decision by ODJFS or eligibility determination by the CDJFS. The NF is required to maintain documentation from the CDJFS or ODJFS district office supporting the information included on the claim and be able to produce said documentation upon request by ODJFS. In no case shall a delay in processing eligibility information at the county level, as required in rule 5101:1-38-02 of the Administrative Code, be a basis for denial of payment under this provision.

(3) When the claim cannot be submitted within three hundred sixty-five days due to the coordination of benefits with medicare and/or other third party payers, pursuant to rule 5101:3-1-08 of the Administrative Code, adjudication will be made if the claim is received within one hundred eighty days of medicare's and/or other third-party payers' adjudication.

(4) Providers may resubmit claims that have been denied. Providers resubmitting claims for reconsideration must meet the following provisions:

(a) The original claim was submitted within three hundred and sixty-five days of the date the service was provided unless the provisions in paragraph (C)(2) or (C)(3) of this rule apply.

(b) The resubmission must be within three hundred and sixty-five days from the date of service or within one hundred and eighty days from the date the claim was denied. ODJFS will not process a resubmitted claim if the claim is received more than seven hundred thirty days after the date of service or discharge except as set forth in paragraph (C)(2) or (C)(3)of this rule.

(c) The resubmitted claim must be in accordance with the specifications defined in paragraphs (A) and (B) of this rule.

(d) Resubmitted claims are not eligible for interest provisions as defined in rule 5101:3-1-19.7 of the Administrative Code.

(D) Claim payment will comply with the prompt payment and interest provisions of rule 5101:3-1-1.7 of the Administrative Code.

(E) Submission of adjustment to claims:

(1) All adjustments shall be submitted using an ANSI 837I transaction and meet the requirements as specified in paragraphs (A)(1), (A)(2), (A)(3) and (A)(4) of this rule.

(2) The submission of an adjustment claim shall be within three hundred and sixty-five days of the actual date of service or one hundred eighty days from ODJFS transaction control number (TCN) date on the original submission whichever is later, unless the provisions in paragraph (C)(2) or (C)(3) of this rule apply. There shall be no submission after seven hundred and thirty days from the actual date of service.

(3) If a prior claim covering only part of the calendar month was submitted and the NF needs to file a claim for an additional part of the same calendar month, the NF shall submit an adjustment claim reflecting the entire calendar month's claim information.

(4) Any interest incurred for an original claim will be included in the adjusted reimbursement amount. Additional interest shall not be paid based upon the length of time required to adjudicate the adjustment transaction. NFs submitting claims for adjustment (i.e., line items or entire claims having an erroneous payment or which are in a paid status with a zero payment) must submit the request within one hundred eighty days from the date the claim was adjudicated.

(F) Patient liability :

(1) The NF shall report on the 837I claim the entire monthly amount of patient liability as determined, in accordance with Chapter 5101:1-39 of the Administrative Code, including for the month of admission, discharge, or transfer to another facility.

(2) Patient liability will be applied toward the claim until medicaid cost of care is offset or patient liability is exhausted. If the patient liability exceeds the medicaid cost of care, the claim will be adjudicated with a zero payment.

(3) In the month a patient switches from medicare to medicaid, the NF shall report the entire monthly amount of patient liability on the 837I claim.

(G) Lump sum payments and their disposition regarding medicaid eligibility are defined in rule 5101:1-39-27.5 of the Administrative Code. If pursuant to rule 5101:1-39-27.5 of the Administrative Code, it is determined that the lump sum is to be paid to medicaid, the NF shall do the following:

(1) When a NF receives a lump sum payment on behalf of a medicaid recipient and the NF was previously paid by medicaid for the recipient's care, the NF shall submit adjustment claims reflecting receipt of the lump sum payment for as many prior months as necessary to fully offset the amount of the lump sum payment.

(2) If the lump sum payment exceeds the amount of prior payments, the NF shall report payments sufficient to offset the current medicaid cost of care on claims submitted for services until the lump sum is exhausted. If the recipient is discharged or passes away prior to exhausting the lump sum payment, the nursing facility shall return the balance to the recipient or his estate.

Effective: 07/01/2005
R.C. 119.032 review dates: 07/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02

5160-3-41 Nursing facilities (NFs) placement into peer groups.

(A) NF peer groups shall be assigned according to sections 5111.231 and 5111.24 of the Revised Code based on the provider's geographical location and the number of licensed beds reported on the provider's annual cost report for the calendar year preceding the fiscal year for which the rate is established.

(1) For a provider new to the medicaid program, the Ohio department of job and family services (ODJFS) shall initially determine the number of beds in the facility from the number of licensed beds documented in the provider agreement. ODJFS shall subsequently determine the number of beds in the facility from the number of beds reported on the provider's annual cost report.

(2) In the case of a change of operator, the entering operator shall be assigned to the peer group that had previously been assigned to the exiting operator on the day immediately preceding the date on which the change of operator occurred. ODJFS shall subsequently determine the number of beds in the facility from the number of licensed beds reported on the entering provider's annual cost report.

(B) No adjustment will be made to the provider's placement in a peer group due to a change in bed size until the first day of the next fiscal year.

Effective: 07/01/2006
R.C. 119.032 review dates: 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.231 , 5111.24 , 5111.25

5160-3-42 Nursing facilities (NFs): chart of accounts.

(A) The Ohio department of medicaid (ODM) requires that all facilities file cost reports annually to comply with section 5165.10 of the Revised Code.

(1) The chart of accounts in table 1 to table 8 of appendix A to this rule is to establish the minimum level of detail to allow for cost report preparation.

(2) If the chart of accounts in appendix A to this rule is not used by the provider, it is the responsibility of the provider to relate its chart of accounts directly to the cost report.

(3) Where a chart of accounts number has sub-accounts that relate directly to a cost report line item, the provider shall capture the information requested so that the information will be broken out for cost reporting purposes.

(4) For example, when revenue accounts appear by payer type, it is required that those charges be reported by payer type where applicable; when salary accounts are differentiated between "supervisory" and "other", it is required that this level of detail be reported on the cost report where applicable.

(B) While the chart of accounts facilitates the level of detail necessary for medicaid cost reporting purposes, providers may find it desirable or necessary to maintain their records in a manner that allows for greater detail than is contained in the chart of accounts in appendix A to this rule .

(1) The chart of accounts in appendix A to this rule allows for a range of account numbers for a specified account.

(2) For example, account 1001 is listed for petty cash, with the next account, cash, beginning at account 1010. Therefore, a provider could delineate sub-accounts 1010-1, 1010-2, 1010-3, 1010-4, to 1010-9 as separate cash accounts. Providers need only use the sub-accounts applicable for their facility.

(C) Within the expense section (tables 5, 6, and 7), accounts identified as "salary" accounts are only to be used to report wages for facility employees.

(1) Wages are to include wages for sick pay, vacation pay and other paid time off, as well as any other compensation to be paid to the employee.

(2) Expense accounts identified as "contract" accounts are only to be used for reporting the costs incurred for services performed by contracted personnel employed by the facility to do a service that would otherwise be performed by personnel on the facility's payroll.

(3) Expense accounts identified as "purchased nursing services" are only to be used for reporting the costs incurred for personnel acquired through a nursing pool agency.

(4) Expense accounts designated as "other" can be used for reporting any appropriate nonwage expenses, including contract services and supplies.

(D) Completion of the cost report as required by section 5111.26 of the Revised Code will require that the number of hours paid be reported (depending on facility type of control, on an accrual or cash basis) for all salary expense accounts. Providers' record keeping should include accumulating hours paid consistent with the salary accounts included within the chart of accounts in appendix A to this rule.

Click to view Appendix

Click to view Appendix

Effective: 01/31/2014
R.C. 119.032 review dates: 11/15/2013 and 01/31/2019
Promulgated Under: 119.03
Statutory Authority: 5165.02
Rule Amplifies: 5165.01 , 5165.10 , 5165.1010 , 5165.34 , 5165.47
Prior Effective Dates: 3/29/85, 8/18/87, 1/20/90 (Emer.), 3/22/90, 10/1/91 (Emer.), 12/20/91, 7/1/93 (Emer.), 9/30/93 (Emer.), 12/30/93, 3/18/94, 12/28/95, 3/20/97 (Emer.), 5/22/97, 3/31/98 (Emer.), 4/27/98, 12/28/00, 9/30/01, 9/30/02, 7/1/05, 2/13/06, 12/31/06, 2/15/10, 1/20/12

5160-3-42.1 Nursing facilities (NFs): medicaid cost report.

The NF medicaid cost report must be filed in accordance with the requirements set forth in rules 5160-3-20 and 5160-3-42 of the Administrative Code using software that is available on the Ohio department of medicaid (ODM) website at least sixty days before the due date of the cost report for each cost reporting period.

Replaces: 5160-3- 42.1

Click to view Appendix

Effective: 01/31/2014
R.C. 119.032 review dates: 01/31/2019
Promulgated Under: 119.03
Statutory Authority: 5165.02
Rule Amplifies: 5165.01 , 5165.10 , 5165.1010 , 5165.34 , 5165.47
Prior Effective Dates: 12/30/77, 8/3/79, 7/1/80, 1/19/84, 3/29/85, 12/31/87 (Emer.), 3/30/88, 7/1/88, 12/20/88 (Emer.), 3/18/89, 12/28/89 (Emer.), 3/22/90, 10/1/90 (Emer.), 12/31/90, 10/1/91 (Emer.), 12/20/91, 12/30/91 (Emer.), 3/19/92, 6/30/92, 12/1/92, 6/26/93, 12/30/93 (Emer.), 5/22/97, 3/31/98 (Emer.), 4/27/98, 12/17/98, 9/12/03, 7/1/05, 2/13/06, 12/31/06, 2/15/10, 1/20/12

5160-3-42.2 [Rescinded] Nursing facilities (NFs): leased staff.

Effective: 08/15/2014
R.C. 119.032 review dates: 05/19/2014
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5165.10
Prior Effective Dates: 1/1/03, 2/9/06

5160-3-42.3 Capital asset and depreciation guidelines - nursing facilities (NFs).

(A) A per diem for depreciation on buildings, components, and equipment used in the provision of patient care that are not reimbursable by medicaid directly to the medical equipment supplier, in accordance with rule 5101:3-3-19 of the Administrative Code is an allowable cost.

(B) For purposes of determining if an expenditure should be capitalized, the following guidelines are utilized:

(1) Any expenditure for an item that costs five hundred dollars or more and has a useful life of two or more years per item must be capitalized and depreciated over the asset's useful life.

(2) A provider may use a capitalization policy less than five hundred dollars per item, but is required to obtain prior approval from the Ohio department of job and family services (ODJFS) if the provider wishes to change its capitalization policy from its initial capitalization policy.

(C) All capital assets shall be depreciated using the straight-line method of depreciation.

(D) For purposes of determining the useful life of a capital asset, NFs shall use the table as set forth in appendix A of this rule or a different useful life if approved by ODJFS. If a capital asset is not reflected on the table as set forth in appendix A of this rule, the internal revenue service publication 946 "How to Depreciate Property" (rev. 2004) shall be used for purposes of determining the useful life of that capital asset.

(E) For newly acquired assets in the month that a capital asset is placed into service, no depreciation expense is recognized as an allowable expense. A full month's depreciation expense is recognized in the month following the month the asset is placed into service.

(F) The disposal of assets shall be accounted for as follows:

(1) For assets not acquired through a change in ownership, in the month that the capital asset is disposed, if the capital asset is not fully depreciated, the allowable depreciation expense is the historical cost of the asset less the accumulated depreciation of the asset. At no time shall an asset be depreciated more than its adjusted basis; or

(2) For assets acquired through a change in ownership, there shall be no recognition of the disposal of individual assets. At the time of a subsequent change of ownership the disposal of all assets acquired through a change of ownership shall be recognized.

(G) Providers shall maintain the following property records:

(1) For assets not acquired through a change in ownership, detailed depreciation schedules listing each asset required; or

(2) For assets acquired through a change in ownership:

(a) Depreciation schedules on a lump sum basis for land, building, and equipment; and

(b) A list of all assets disposed after the change in ownership with the applicable dates of disposal.

APPENDIX A

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

LAND IMPROVEMENTS -- USEFUL LIFE

BUMPERS 5

CULVERTS 18

FENCING

BRICK OR STONE 25

CHAIN-LINK 15

WIRE 5

WOOD 8

FLAG POLE 20

GUARD RAILS 15

HEATED PAVEMENT 10

LANDSCAPING 10

LAWN SPRINKLER SYSTEM 15

PARKING LOT, OPEN-WALL 20

PARKING LOT GATE/S 3

PARKING LOT STRIPING 2

PAVING (INCLUDING ROADWAYS, WALKS, AND PARKING)

ASPHALT 8

BRICK 20

CONCRETE 15

GRAVEL 5

RETAINING WALL 20

SEPTIC SYSTEM 15

SHRUBS AND LAWNS 5

SIGNS, METAL OR ELECTRIC 10

SNOW-MELTING SYSTEM 5

TREES 20

TURF, ARTIFICIAL 5

UNDERGROUND UTILITIES

SEWER LINES 25

WATER WELLS 25

YARD LIGHTING 15

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

BUILDINGS - ALL 40

BUILDING COMPONENTS

CANOPIES 15

CARPENTRY WORK 15

CAULKING 10

CEILING FINISHES

GYPSUM 10

PLASTER 12

COMPUTER FLOORING 10

CORNER GUARDS 10

CUBICLE TRACKS 20

DESIGNATION SIGNS 5

DOORS AND FRAMES

AUTOMATIC 10

HOLLOW METAL 20

WOOD 15

DRAPERY TRACKS 10

DRILLED PIERS 40

FLOOR FINISHES

CARPET 5

CERAMIC 20

CONCRETE 20

QUARRY 20

TERRAZZO 15

VINYL 10

FOLDING PARTITIONS 10

INTERIOR FINISHES 15

LOADING DOCK BUMPERS AND LEVELERS 10

MILLWORK 15

OVERHEAD DOORS 10

PARTITIONS, INTERIOR 15

PARTITIONS, TOILET 20

RAILINGS

FREESTANDING (EXTERIOR) 15

HANDRAILS (INTERIOR) 15

ROOF COVERING 10

SKYLIGHTS 20

STOREFRONT CONSTRUCTION 20

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

WALL COVERING

PAINT 5

WALLPAPER 5

X-RAY PROTECTION 10

FIXED EQUIPMENT

BENCHES, BINS, CABINETS, COUNTERS, AND SHELVING, BUILT-IN 20

CABINET, BIOLOGICAL SAFETY 15

CANOPY-VENTILATING FOR LAUNDRY IRONER 15

COAT RACK 20

CONVEYOR SYSTEM, LAUNDRY 10

COOLER, WALK-IN 15

CURTAINS AND DRAPES 5

EMERGENCY GENERATOR SET 20

GENERATOR CONTROLS 12

HOOD, FUME 15

FIRE PROTECTION IN HOODS 10

ICU AND CCU COUNTERS 15

ILLUMINATOR

MULTIFILM 10

SINGLE 10

LAMINAR FLOW SYSTEM 15

LOCKERS, BUILT-IN 15

MAILBOXES, BUILT-IN 20

MEDICINE PREPARATION STATION 15

MIRRORS, TRAFFIC AND/OR WALL MOUNTED 10

NARCOTICS SAFE 20

NURSES' COUNTER, BUILT-IN 15

PASS-THROUGH BOXES 15

PATIENTS' CONSOLES 15

PATIENTS' WARDROBES AND VANITIES, BUILT-IN 15

PROJECTION SCREENS 10

SINK AND DRAINBOARD 20

STERILIZER, BUILT-IN 15

TELEPHONE ENCLOSURE 10

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

BUILDING SERVICES EQUIPMENT

AIR-CONDITIONING EQUIPMENT

CENTRIFUGAL CHILLER 15

COMPRESSOR, AIR 15

CONDENSATE TANK 10

CONDENSER 15

CONTROLS 10

COOLER AND DEHUMIDIFIER 10

COOLING TOWER

METAL 20

WOOD 20

DUCT WORK 20

FAN, AIR-HANDLING AND VENTILATING 20

PIPING 20

PRECIPITATOR 10

PUMP 10

AIR-CONDITIONING SYSTEM

LARGE (OVER 20 TONS) 10

MEDIUM (5-20 TONS) 10

SMALL (UNDER 5 TONS) 5

AIR CURTAIN 15

ANTENNA SYSTEM 10

BOILER 20

DEAERATOR SYSTEM 15

BOILER SMOKESTACK, METAL 20

CLEAN-AIR EQUIPMENT 15

CLOCK SYSTEM, CENTRAL 15

DOOR ALARM 10

DOOR-CLOSING DEVICES, FOR FIRE ALARM SYSTEM 15

ELECTRIC LIGHTING AND POWER

COMPOSITE 18

CONDUIT AND WIRING 20

EMERGENCY LIGHTING SYSTEM 15

FEED WIRING 20

FIXTURES 10

SWITCH GEAR 15

TRANSFORMER 20

ELEVATOR

DUMBWAITER 20

FREIGHT 20

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

PASSENGER, HIGH-SPEED AUTOMATIC 20

PASSENGER, OTHER 20

EMERGENCY GENERATOR 20

CONTROLS 12

ESCALATOR 20

FANS, CEILING-MOUNTED 10

FIRE PROTECTION SYSTEM

FIRE ALARM SYSTEM 10

FIRE PUMP 20

SMOKE AND HEAT DETECTORS 10

SPRINKLER SYSTEM 25

TANK AND TOWER 25

FURNACE, DOMESTIC 15

HEATING, VENTILATING, AND AIR-CONDITIONING (COMPOSITE SYSTEM) 15

HUMIDIFIER 15

INCINERATOR, INDOOR 10

INSULATION, PIPE 15

INTERCOM SYSTEM 10

LABORATORY PLUMBING, PIPING 20

MAGNETIC DOOR HOLDERS 10

MEDICAL GAS PANELS 10

NURSE CALL SYSTEM 10

OIL STORAGE TANK 20

OXYGEN, GAS, AND AIR PIPING 20

PAGING SYSTEM 10

PHYSICIAN'S IN-AND-OUT REGISTER, BUILT-IN 10

PLUMBING, COMPOSITE 20

FIXTURES 20

PIPING 25

PUMP 15

PNEUMATIC TUBE SYSTEM 15

RADIATOR

CAST-IRON 25

FINNED TUBE 15

SEWERAGE, COMPOSITE 25

PIPING 20

SUMP PUMP AND SEWERAGE EJECTOR 10

SOLAR HEATING EQUIPMENT 10

SURGE SUPPRESSING SYSTEM 15

TELEPHONE SYSTEM 10

TELEVISION ANTENNA SYSTEM 10

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

TELEVISION SATELLITE DISH 10

TEMPERATURE CONTROLS, COMPUTERIZED 10

UNIT HEATER 10

VACUUM CLEANING SYSTEM 15

WATER FOUNTAIN 10

WATER HEATER, COMMERCIAL 10

WATER PURIFIER 10

WATER SOFTENER 10

WATER STORAGE TANK 20

WATER WELLS 25

ALPHABETIZED LIST OF EQUIPMENT ITEMS

ACCELERATOR 7

ACCOUNTING/BOOKKEEPING MACHINE 5

ADDING MACHINE 5

AIR-CONDITIONER, WINDOW 5

ALTERNATING PRESSURE PAD 10

AMBULANCE 4

AMINO ACID ANALYZER 7

AMPLIFIER 10

ANAEROBE CHAMBER 15

ANALYZER, HEMATOLOGY 7

ANATOMICAL MODEL 10

ANESTHESIA UNIT 7

ANKLE EXERCISER 15

APNEA MONITOR 7

APRON, LEAD-LINED 4

ARTHROSCOPE 5

ARTHROSCOPY INSTRUMENTATION 3

ASPIRATOR 10

AUDIOMETER 10

AUTOCLAVE 10

AUTOMOBILE

DELIVERY 4

PASSENGER 4

AUTOSCALER, IONIC 10

BACTERIOLOGY ANALYZER 8

BACTI INCINERATOR 5

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

BALANCE

ANALYTICAL 10

ELECTRONIC 7

PRECISION MECHANICAL 10

BASAL METABOLISM UNIT 8

BASSINET 15

BATH

PARAFFIN 7

SEROLOGICAL 7

SITZ 10

WATER 7

WHIRLPOOL 10

BATTERY CHARGER 5

BED

BIRTHING 10

ELECTRIC 12

FLOTATION THERAPY 10

HYDRAULIC 15

LABOR 15

MANUAL 15

ORTHOPEDIC 15

BEDPAN WASHER 15

BEEPERS, PAGING 3

BENCH, METAL OR WOOD 15

BIN, METAL OR WOOD 15

BINDER, PUNCH MACHINE 10

BIOCHEMICAL ANALYSIS UNIT 7

BIOCHROMATIC ANALYZER 7

BIOFEEDBACK MACHINE 8

BIOMAGNETOMETER 7

BIPOLAR COAGULATOR 7

BLANKET DRYER 15

BLANKET WARMER 15

BLOOD CELL COUNTER 5

BLOOD CHEMISTRY ANALYZER, AUTOMATED 5

BLOOD CULTURE ANALYZER 8

BLOOD GAS ANALYZER 5

BLOOD GAS APPARATUS, VOLUMETRICS 8

BLOOD PRESSURE DEVICE, ELECTRONIC 6

BLOOD TRANSFUSION APPARATUS 6

BLOOD WARMER 7

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

BLOOD WARMER COIL 7

BONE SURGERY APPARATUS 3

BOOKCASE, METAL OR WOOD 20

BOTTLE WASHER 10

BREATHING UNIT, POSITIVE-PRESSURE 8

BROILER 10

BRONCHOSCOPE

FLEXIBLE 3

RIGID 3

BULLETIN BOARD 10

BURNISHER, SILVERWARE 15

CABINET

BEDSIDE 15

FILE 15

INSTRUMENT 15

METAL OR WOOD 15

PHARMACY 15

SOLUTION 15

X-RAY 15

CAGE, ANIMAL 10

CALCULATOR 5

CAMERA

IDENTIFICATION 5

SURGICAL 5

TELEVISION MONITORING, COLOR OR BLACK-AND-WHITE 5

VIDEOTAPE, COLOR OR BLACK-AND-WHITE 5

CAN OPENER, ELECTRIC 10

CAPSULE MACHINE 10

CARBON MONOXIDE RECORDER/DETECTOR 10

CARDIAC MONITOR 5

CARDIOSCOPE 8

CART

EMERGENCY-ISOLATION 10

FOOD/TRAY, HEATED-REFRIGERATED 10

LINEN 10

MAID 10

MEDICINE 10

SUPPLY 10

UTILITY 10

CASH REGISTER 5

CASPAR ACF INSTRUMENT AND PLATE SYSTEM 7

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

CASSETTE CHANGER 8

CATHODE-RAY TUBE (CRT) 3

CAUTERY UNIT

DERMATOLOGY 7

GYNECOLOGY 7

CELL FREEZER 7

CELL WASHER 5

CENTRAL DATA PROCESSING UNIT 10

CENTRAL SUPPLY FURNITURE 15

CENTRIFUGE 7

REFRIGERATED 5

CEREBRAL FUNCTION MONITOR 7

CHAIR

BLOOD DRAWING 10

DENTAL 15

EXECUTIVE 15

FOLDING 10

GERIATRIC 10

HYDRAULIC, SURGEON'S 15

KINETRON 15

PODIATRIC 15

SHOWER/BATH 10

SIDE 15

SPECIALIST'S 15

CHART RACK 20

CHART RECORDER 10

CHECK SIGNER 10

CHILD IMMOBILIZER 15

CHLORIDIOMETER 10

CHROMATOGRAPH, GAS 7

CLINICAL ANALYZER 5

CLOCK 10

CLOPAY WRAPPING MACHINE 10

CLOTHES LOCKER

FIBERGLASS OR METAL 15

LAMINATE OR WOOD 12

COAGULATION ANALYZER 5

COFFEE MAKER 5

COLD-PACK UNIT, FLOOR 10

COLLATOR, ELECTRIC 10

COLONOSCOPE 3

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

COLORIMETER 7

COLPOSCOPE, WITH FLOOR STAND 8

COMPACTOR, WASTE 10

COMPRESSOR, AIR 12

COMPUTER

CARIDIAL OUTPUT 5

CLINICAL 5

DISK DRIVE 5

LARGE 5

MICRO 5

MINI (PERSONAL) 5

PRINTER 5

SOFTWARE 5

TERMINAL 5

COMPUTER-ASSISTED TOMOGRAPHY (CT) SCANNER 5

CONDUCTIVITY TESTER 5

CONVEYOR, TRAY 10

COOKER, PRESSURE, FOR FOOD 10

COOLER, WALK-IN, FREESTANDING 15

CO-OXIMETER 10

CREDENZA 15

CRIB 15

CROUPETTE 10

CRYOOPHTHALMIC UNIT, WITH PROBES 7

CRYOSTAT 7

CRYOSURGICAL UNIT 10

CUTTER

CLOTH, ELECTRIC 10

FOOD 10

CYCLOTRON 7

CYSTIC FIBROSIS TREATMENT SYSTEM 10

CYSTOMETER 10

CYSTOMETROGRAM UNIT 10

CYSTOSCOPE 3

DATA CARD PROCESSING UNIT - (INCLUDING KEYPUNCH, VERIFIER, READER, AND SORTER) 5

DATA PRINTING UNIT 5

DATA STORAGE UNIT

MECHANICAL 10

NONMECHANICAL 15

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

DATA TAPE PROCESSING UNIT - (INCLUDING CONTROLLER, DRIVE, AND TAPE DECK) 5

DECALCIFIER 10

DEFIBRILLATOR 5

DEIONIZED WATER SYSTEM 7

DENSITOMETER, RECORDING 5

DENTAL DRILL, WITH SYRINGE 3

DERMATOME 10

DESK, METAL OR WOOD 20

DIAGNOSTIC SET 10

DIATHERMY UNIT 10

DICTATING EQUIPMENT 5

DIGITAL FLUOROSCOPY UNIT 5

DIGITAL RADIOGRAPHY UNIT 5

DILUTER 10

DISH STERILIZER 10

DISHWASHER 10

DISINFECTOR 10

DISPENSER

ALCOHOL 10

BUTTER, REFRIGERATED 10

MILK OR CREAM 10

DISPLAY CASES 20

DISTILLING APPARATUS 15

DOPPLER 5

DOSE CALIBRATOR 5

DRESSER 15

DRILL PRESS 20

DRYER

CLOTHES 10

HAIR 5

SONIC 10

DRYING OVEN, PAINT SHOP 10

DUPLICATOR 5

ECHOCARDIOGRAPH SYSTEM 5

ECHOVIEW SYSTEM 5

ELECTROCARDIOGRAPH 7

ELECTROCARDIOSCANNER (HOLTER MONITOR SCANNER) 7

ELECTROENCEPHALOGRAPH 7

ELECTROLYTE ANALYZER 5

ELECTROMYOGRAPH 7

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

ELECTROPHORESIS UNIT 7

ELECTROSURGICAL UNIT 7

ENLARGER 10

ERGOMETER 10

EVACUATOR 10

EVOKED POTENTIAL UNIT 10

EXERCISE APPARATUS 15

EXERCISE EQUIPMENT, OUTDOOR 10

EXERCISE SYSTEM, COMPUTER-ASSISTED 5

EXERCISER, ORTHOTRON 10

EXTRACTOR, LAUNDRY 15

EYE SURGERY EQUIPMENT (PHACOEMULSIFIER) 7

FACSIMILE TRANSMITTER 3

FIBEROPTIC EQUIPMENT 5

FIBROMETER 7

FILES, ELECTRIC ROTARY 15

FILING SYSTEM, PORTABLE 20

FILM CHANGER 8

FILM VIEWER 10

FLOOR-BUFFING AND POLISHING MACHINE 5

FLOOR-SCRUBBING MACHINE 5

FLOOR-WAXING MACHINE 5

FLOW CYTOMETER 5

FLUID SAMPLE HANDLER 5

FLUORIMETER 10

FLUOROSCOPE 8

FOLDER, FLATWORK 15

FOOD CHOPPER 10

FOOD SERVICE FURNITURE 15

FRAME, TURNING 15

FREEZER, ULTRACOLD 10

FRYER, DEEP-FAT 10

FURNACE, LABORATORY 10

GAMMA CAMERA 5

GAMMA COUNTER 7

GAMMA KNIFE 10

GAMMA WELL SYSTEM 7

GARBAGE DISPOSAL, COMMERCIAL 5

GAS ANALYZER 8

GEIGER COUNTER 10

GENERATOR 5

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

GLASSWARE WASHER 8

GLOVES, LEAD-LINED 3

GRAPHOTYPE 15

GRIDDLE 10

GRINDER, FOOD WASTE 10

HAND DYNAMOMETER 10

HEART-LUNG SYSTEM 8

HEAT SEALER 5

HELICOPTER 4

HEMODIALYSIS UNIT 5

HEMOGLOBINOMETER 7

HEMOPHOTOMETER 10

HIGH-DENSITY MOBILE FILM SYSTEM 10

HOIST, CHAIN OR CABLE 12

HOLTER

ELECTROCARDIOGRAPH 7

ELECTROENCEPHALOGRAPH 7

HOMOGENIZER 10

HOOD, EXHAUST OR BACTI 10

HOT-FOOD BOX 15

HOTPLATE 5

HOUSEKEEPING FURNITURE 15

HUMIDIFIER 8

HYDROCOLLATOR 10

HYDROTHERAPY EQUIPMENT 15

HYFRECATOR 10

HYPERBARIC CHAMBER 15

HYPOTHERMIA APPARATUS 10

ICE CREAM FREEZER 10

ICE CREAM (SOFT) MACHINE 10

ICE CREAM STORAGE CABINET 10

ICE CUBE-MAKING EQUIPMENT 10

ICU AND CCU FURNITURE 15

IMAGE ANALYZER 5

IMAGE INTENSIFIER 5

IMMUNODIFFUSION EQUIPMENT 10

IMPRINTER

ADDRESS 5

EMBOSSED PLATE 10

IMX ANALYZER 7

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

INCUBATOR

LABORATORY 10

NURSERY 10

INDICATOR, REMOTE 10

INFANT CARE CENTER 10

INHALATOR 10

IN-SERVICE EDUCATION FURNITURE 15

INSUFFLATOR 5

INTEGRATOR 10

INTERCOM 10

INTRAARTERIAL SHAVER 10

IONTOPHORESIS UNIT 8

IRONER, FLATWORK 15

ISODENSITOMETER 7

ISOLATION CHAMBER 12

ISOTOPE EQUIPMENT 7

ISOTOPE SCANNER 7

KETTLE, STEAM-JACKETED 15

KEY MACHINE 10

KILN 10

K-PADS 5

KYMOGRAPH 10

LABEL MAKER 10

LABOR AND DELIVERY FURNITURE 15

LABORATORY FURNITURE 15

LAMINATOR 10

LAMP

BILIRUBIN 10

DEEP-THERAPY 10

EMERGENCY 10

INFRARED 10

MERCURY QUARTZ 10

SLIT 10

LAPAROSCOPE 3

LARYNGOSCOPE 3

LASER

CORONARY 2

SURGICAL 5

LASER POSITIONER 5

LASER SMOKE EVACUATOR 5

LATHE 15

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

LAWN AND PATIO FURNITURE 5

LAWN MOWER, POWER 3

LIBRARY FURNITURE 20

LIFTER, PATIENT 10

LIGHT

DELIVERY 15

EXAMINING 10

PORTABLE, EMERGENCY 10

LINAC SCALPEL 5

LINEAR ACCELERATOR 7

LINEN

DRYER 15

PRESS 15

TABLE 15

WASHER 15

LINT COLLECTOR 15

LITHOTRIPTER, EXTRACORPOREAL SHOCK-WAVE (ESWL) 5

LOOM 15

LOWERATOR 10

MAGNETIC RESONANCE IMAGING (MRI) EQUIPMENT 5

MAILING MACHINE 10

MAMMOGRAPHY UNIT

FIXED 5

MOBILE (VAN) 8

MANNEQUIN 10

MARKING MACHINE 10

MAROGRAPH 7

MASS SPECTROPHOTOMETER 7

MEAT CHOPPER 10

MICROBIOLOGY ANALYZER 8

MICROFILM UNIT 10

MICROPHONE 5

MICROPROJECTOR 10

MICROSCOPE 7

MICROTOME 7

MICROTRON POWER SYSTEM 7

MIRROR, THERAPY 15

MIXER, COMMERCIAL 10

MUSCLE STIMULATOR 10

NATURAL CHILDBIRTH BACKREST 10

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

NEBULIZER

PNEUMATIC 10

ULTRASONIC 10

NEPHROSCOPE 7

NEUROLOGICAL SURGICAL TABLE HEADREST 10

NEUTRON BEAM ACCELERATOR 8

NONINVASIVE CO2 MONITOR 7

NOURISHMENT ICE STATION 8

NURSING SERVICE FURNITURE 15

OFFICE FURNITURE 12

OPERATING ROOM FURNITURE 15

OPERATING STOOL 15

OPHTHALMOSCOPE 10

OPTICAL READERS 5

ORGAN 10

ORTHOTRON SYSTEM 10

ORTHOUROLOGICAL INSTRUMENTS 10

OSCILLOSCOPE 7

OSMOMETER 7

OTOSCOPE 7

OTTOMAN 10

OVEN

BAKING 10

MICROWAVE 5

PARAFFIN 10

ROASTING 10

STERILIZING 10

OXIMETER 10

OXYGEN ANALYZER 7

OXYGEN TANK, MOTOR, AND TRUCK 8

PACEMAKER, CARDIAC (EXTERNAL) 5

PACING SYSTEM ANALYZER 7

PACKAGING MACHINE 10

PAINT SPRAY BOOTH 15

PAINT-SPRAYING MACHINE 10

PANENDOSCOPE 10

PAPER BALER 15

PAPER BURSTER 8

PAPER CUTTER 10

PAPER JOGGER 10

PAPER SHREDDER 5

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

PARALLEL BARS 15

PARKING LOT SWEEPER 5

PARTITIONS, MOVABLE OFFICE 10

PATIENT MONITORING EQUIPMENT 10

PATIENT ROOM FURNITURE 10

PELVISCOPE 7

PERCUSSOR 5

PERFORATOR 10

PERIPHERAL ANALYZER 10

pH GAS ANALYZER 10

pH METER 10

PHONOCARDIOGRAPH 8

PHOTOCOAGULATOR 10

PHOTOCOPIER 5

PHOTOGRAPHY APPARATUS, GROSS PATHOLOGY 10

PHOTOMETER 8

PHOTOTHERAPY UNIT 10

PHYSICIANS' IN-AND-OUT REGISTER, PORTABLE 10

PHYSIOLOGICAL MONITOR 7

PHYSIOSCOPE 10

PIANO 20

PIPE CUTTER-THREADER 10

PIPETTE, AUTOMATIC 10

PLANER AND SHAPER, ELECTRIC 10

PLASMA FREEZER 10

PLATE-BENDING PRESS 10

PLATELET ROTATOR 20

PLATEMAKER

COMPUTERIZED 5

NONCOMPUTERIZED 10

POPCORN MACHINE 8

POSITION EMISSION TOMOGRAPHY (PET) SCANNER 5

POWER SUPPLY 10

PRESS, LAUNDRY 15

PRINTING PRESS 10

PROCTOSCOPE 3

PROJECTOR

OVERHEAD 10

SLIDE 10

VIDEO 10

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

PROTHROMBIN TIMER, AUTOMATED 8

PROTON BEAM ACCELERATOR 7

PULMONARY FUNCTION ANALYZER 8

PULMONARY FUNCTION EQUIPMENT 8

PULSED OXYGEN CHAMBER 10

PULSE OXYMETER 7

PUMP

BREAST 10

INFUSION 10

STOMACH 10

SUCTION 10

SURGICAL 10

VACUUM 10

RADIATION METER 8

RADIOACTIVE SOURCE, COBALT 5

RADIOGRAPHIC DUPLICATING PRINTER 8

RADIOGRAPHIC-FLUOROSCOPIC COMBINATION 5

RADIOGRAPHIC HEAD UNIT 5

RANGE, DOMESTIC 10

RATE METER, DUAL 10

RECORDER, TAPE 10

REFRACTOMETER 10

REFRIGERATOR

BLOOD BANK 10

DOMESTIC 10

COMMERCIAL 10

UNDERCOUNTER 10

REMOTE CONTROL RECEIVER 10

RESUSCITATOR 10

RETRACTOR 5

RHINOSCOPE 10

RINSER, SONIC 10

ROTARY TILLER 10

ROTOOSTEOTOME UNIT 10

SAFE 20

SANITIZER 10

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

SAW

AUTOPSY 10

BAND 10

BENCH, ELECTRIC 10

MEAT-CUTTING 10

NEUROSURGICAL 10

SURGICAL, ELECTRIC 10

SCAFFOLD 10

SCALE

BABY 15

BED 10

CHAIR 10

CLINICAL 10

METABOLIC 10

POSTAL 10

SCALE, LAUNDRY

MOVEABLE 10

PLATFORM 15

SCINTILLATION SCALER 8

SCREEN, PROJECTOR 10

SENSITOMETER 10

SERIOGRAPH, AUTOMATIC 8

SETTEE 12

SEWING MACHINE 15

SHAKING MACHINE (VORTEXER) 8

SHARPENER, MICROTOME KNIFE 10

SHEARS, SQUARING, FLOOR 12

SHELVING, PORTABLE, STEEL 20

SHOULDER WHEEL 20

SIGMOIDOSCOPE 3

SIGNAL-AVERAGE EKG 5

SIMULATOR 5

SINGLE-PHOTON EMISSION COMPUTED TOMOGRAPHY (SPECT) SCANNER 5

SINUSCOPE 7

SKELETON 10

SLICER

BREAD 10

MEAT 10

SLIDE STAINER, LABORATORY 7

SNOWBLOWER 5

SOFA 12

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

SPECTROPHOTOMETER 8

SPECTROSCOPE 10

SPHYGMOMANOMETER 10

SPIROMETER 8

STALL BARS 15

STAMP MACHINE 10

STAND

BASIN 15

INTRAVENOUS 15

IRRIGATING 15

MAYO 15

STAPLER, ELECTRIC OR AIR 10

STEAMER, VEGETABLE 10

STEAM-PACK EQUIPMENT 10

STENCIL MACHINE 10

STEREO EQUIPMENT 5

STEREO TACTIC FRAME 5

STERILIZER, MOVABLE 12

STERIS STERILIZATION SYSTEM 7

STETHOSCOPE 5

STRESS TESTER 10

STRETCHER 10

SURGICAL SHAVER 5

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

TABLE

ANESTHETIC 15

AUTOPSY 20

ELECTROHYDRAULIC TILT 10

EXAMINING 15

FOLDING 10

FOOD PREPARATION 15

FRACTURE 15

INSTRUMENT 15

LIGHT 15

METAL 15

OBSTETRICAL 20

OPERATING 15

ORTHOPEDIC 10

OVERBED 15

POOL 10

REFRIGERATED 10

THERAPY 15

TRACTION 10

UROLOGICAL 15

WOOD 15

TANK

CLEANING 10

FULL-BODY 15

HOT-WATER 10

THERAPY 15

TDX ANALYZER 7

TELEMETRY UNIT 5

TELEPHONE, CORDLESS 5

TELEPHONE EQUIPMENT FOR DEAF 5

TELEPHONE MONITORS 10

TELESCOPE, MICROLENS 10

TELESCOPIC SHOULDER WHEEL 15

TELETHERMOMETER 10

TELEVISION

MONITOR 5

RECEIVER 5

TENT

AEROSOL 10

OXYGEN 8

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

THERMOMETER, ELECTRIC 5

TIME RECORDING EQUIPMENT 10

TISSUE-EMBEDDING CENTER 8

TISSUE PROCESSOR 7

TITRATOR, AUTOMATIC 10

TOASTER, COMMERCIAL 10

TONOMETER 10

TOTALAP 10

TOURNIQUET, AUTOMATIC 10

TOURNIQUET SYSTEM 7

TRACTION UNIT 10

TRACTOR 10

TRANSCRIBING EQUIPMENT 5

TRANSCUTANEOUS NERVE STIMULATOR SYSTEM 5

TRANSESOPHAGEAL TRANSDUCER 5

TREADMILL, ELECTRIC 8

TRUCK (AUTOMOTIVE)

FORKLIFT 10

MULTIPURPOSE FILLING 15

PICKUP 4

PLATFORM 12

VAN 4

TRUCK (HAND)

HOT-FOOD 10

TRAY 12

TUBE DRYER 10

TUBE TESTER 5

TUMBLER, LAUNDRY 15

TYPEWRITER

ELECTRIC 5

MANUAL 5

ULTRASONIC CLEANER 10

ULTRASONIC FETAL HEART MONITOR 7

ULTRASOUND, DIAGNOSTIC 5

ULTRASOUND UNIT, THERAPEUTIC 7

URN, COFFEE 10

VACUUM CLEANER 8

VACUVETTE 10

VALET, OFFICE 15

VEGETABLE PEELER, ELECTRIC 10

VENDING MACHINE 10

ESTIMATED USEFUL LIVES OF CAPITAL ASSETS

USEFUL LIFE

VENTILATOR, RESPIRATORY 10

VIAL FILLER 10

VIBRATOR 10

VIDEO

CAMERA 5

CASSETTE 5

LIGHT SOURCE 5

MONITOR 5

PRINTER 5

VISE, LARGE BENCH 20

WALKIE-TALKIE 5

WARMER

DISH 10

FOOD 10

WASHING MACHINE

COMMERCIAL 10

DOMESTIC 8

WATER COOLER, BOTTLE 10

WELDER 10

WHEELCHAIR 5

WIRE TIGHTENER-TWISTER 10

WORD PROCESSOR

LARGE 5

SMALL 5

WORK STATION 10

X-RAY EQUIPMENT

DEVELOPING TANK 10

FILM DRYER 8

FILM PROCESSOR 8

FURNITURE 15

IMAGE INTENSIFIER 5

INTENSIFYING SCREENS 5

SILVER RECOVERY UNIT 7

X-RAY UNIT

FLUOROSCOPIC 5

MOBILE 5

RADIOGRAPHIC 5

SUPERFICIAL THERAPY 5

WIRING 5

Replaces: 5101:3-3- 51.1

Effective: 02/09/2006
R.C. 119.032 review dates: 02/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.25
Rule Amplifies: 5111.25
Prior Effective Dates: 9/30/93, 7/4/02

5160-3-42.4 Nursing facilities (NFs): nonreimbursable costs.

The following costs are not reimbursable to NFs through the NF per diem, except as specified under Chapter 5101:3-3 of the Administrative Code. Nonreimbursable costs include but are not limited to:

(A) Fines or penalties paid under sections 5111.271 , 5111.28 , 5111.35 to 5111.62 , and 5111.99 of the Revised Code.

(B) Disallowances made during the audit of the NF's cost report which are sanctioned through adjudication in accordance with Chapter 119. of the Revised Code.

(C) Costs which exceed prudent buyer tests of reasonableness which may be applied pursuant to the provisions of the provider reimbursement manual (centers for medicare and medicaid services (CMS) Publication 15-1, www.cms.hhs.gov/manuals), during the audit of the NF's cost report.

(D) The costs of ancillary services rendered to NF residents by providers who bill medicaid directly. Ancillary services include but are not limited to: physicians, legend drugs, radiology, and laboratory.

(E) Cost per case-mix units in excess of the applicable peer group ceiling for direct care cost.

(F) Expenses in excess of the capital costs limitations.

(G) Expenses associated with lawsuits filed against the Ohio department of job and family services (ODJFS) which are not upheld by the courts.

(H) Cost of meals sold to visitors or public (i.e., meals on wheels).

(I) Cost of supplies or services sold to nonfacility residents or public.

(J) Cost of operating a gift shop.

Effective: 03/19/2012
R.C. 119.032 review dates: 12/15/2011 and 03/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.26 , 5111.262
Rule Amplifies: 5111.20 , 5111.26 , 5111.262 , 5111.271
Prior Effective Dates: 12/30/77, 8/3/79, 7/1/80, 1/1/84, 7/1/88 (Emer.), 9/25/88, 12/30/88 (Emer.), 3/31/89 (Emer.), 6/18/89, 10/1/89, 12/20/91, 9/30/93 (Emer.), 1/1/94, 12/17/98, 9/12/03, 2/9/06, 2/15/10

5160-3-43 Nursing facilities (NFs): method for establishing the total prospective rate. [Rescinded].

Rescinded eff 2-2-06

5160-3-43.1 Nursing facility (NF) case mix assessment instrument: minimum data set version 3.0 (MDS 3.0).

(A) As used in this rule:

(1) "Annual facility average case mix score" is the score used to calculate the facility's cost per case-mix unit.

(2) "Assessment reference date (ARD)" is the last day of the observation (or "look back") period that the MDS 3.0 assessment covers for the resident.

(3) "Care area assessment (CAA) process" is the mechanism to facilitate care planning decisions and includes care area triggers (CATs), assessment of a triggered care area to facilitate care planning decision making and completion of the CAA summary (on the MDS 3.0, section V, item V0200) titled CAAs and care planning.

(4) "Case mix report" is a report generated by the Ohio department of job and family services (ODJFS) and distributed to the provider on the status of all MDS 3.0 assessment data that pertains to the calculation of a quarterly, semiannual or annual facility average case mix score.

(5) "Comprehensive assessment" means an assessment that includes completion of not only the appropriate MDS 3.0 assessment type listed in paragraph (B)(2) of this rule and designated for use in Ohio but also completion of the CAA process.

(6) "Critical elements" are data items from a resident's MDS 3.0 that ODJFS verifies prior to determining a resident's resource utilization group, version III (RUG III) class.

(7) "Critical errors" are errors in the MDS 3.0 critical elements that prevent ODJFS from determining the resident's RUG III classification.

(8) "Default group" is RUG III group forty-five, the case mix group assigned to residents with MDS 3.0 records with inconsistent date fields, missing, incomplete, out of range or inaccurate data, including inaccurate resident identifiers any of which precludes grouping the record into RUG III groups one through forty-four.

(9) "Encoded," when used with reference to a record, means that the record has been recorded in electronic format. The record must be encoded in accordance with the United States centers for medicare and medicaid services (CMS) uniform data submission document and state specifications.

(10) "Filing date" is the deadline for submission of the NF's MDS 3.0 assessment data that will be used to calculate the preliminary facility quarterly average case mix score. The filing date is the fifteenth calendar day following the reporting period end date (RPED).

(11) "Medicare required assessment" means the MDS 3.0 specified for use in Ohio that is required only for facilities participating in the medicare prospective payment system but does not include the CAA process.

(12) "Omnibus Budget Reconciliation Act of 1987 (OBRA 1987)" is the statutory authority for the RAI which specifies the minimum data set (MDS) of core elements for use in conducting assessments of nursing home residents. Assessments are federally mandated and must be performed for all residents of medicare and/or medicaid certified nursing homes.

(13) "Other medicare required assessment (OMRA)" is an unscheduled MDS 3.0 PPS assessment required to be completed during a resident's medicare "Part A" SNF covered stay based on the start or cessation of rehabilitation services.

(14) "PPS assessment" is the tool that skilled nursing facilities (SNFs) use to assess the clinical condition for each medicare resident receiving "Part A" SNF level care for reimbursement under the SNF PPS.

(15) "Quarterly facility average total case mix score" is the facility average case mix score based on both medicaid and non-medicaid resident data submitted for one reporting quarter and calculated pursuant to paragraph (B)(1) of rule 5101:3-3-43.3 of the Administrative Code.

(16) "Quarterly facility average medicaid case mix score" is the facility average case mix score based on only medicaid resident data submitted for one reporting quarter and calculated pursuant to paragraph (B)(2) of rule 5101:3-3-43.3 of the Administrative Code.

(17) "Quarterly review assessment" means an assessment that is normally conducted no less than once every three months using the MDS 3.0 designated for use in Ohio that does not include the CAA process.

(18) "Record" means a resident's encoded MDS 3.0 assessment as described in paragraphs (B)(1) to (B)(4) of this rule.

(19) "Relative resource weight" is the measure of the relative costliness of caring for residents in one case mix group versus another, indicating the relative amount and cost of staff time required on average for defined worker classifications to care for residents in a single case mix group. The methodology for calculating relative resource weights is described in paragraph (H) of rule 5101:3-3-43.2 of the Administrative Code.

(20) "Reporting period end date" (RPED) is the last day of each calendar quarter.

(21) "Reporting quarter" is the calendar quarter in which the MDS 3.0 is completed, as indicated by the assessment reference date in MDS 3.0 section A, item A2300, except as specified in paragraphs (C)(7) and (C)(8) of this rule.

(22) "Resident Assessment Instrument (RAI)" is the instrument used by NFs in Ohio to comply with 42 C.F.R. 483.20 (effective 8/11/09 http://ecfr.gpoaccess.gov/cgi/t/text/text-idx? sid=2e0cc442b567f836691e8d460522a8a3 &c=ecfr&tpl=/ecfrbrowse/Title42/42tab_02.tpl) and provides a comprehensive, accurate, standardized, reproducible assessment of each long term care facility resident's functional capabilities and identifies medical problems. The Ohio specified and federally approved instrument is composed of the MDS 3.0, and CAA process.

(23) "Resident case mix score" is the relative resource weight for the RUG III group to which the resident is assigned based on data elements from the resident's MDS 3.0 assessment.

(24) "Resident identifier code" is an alternative resident identifier if the resident does not have a social security number. The resident identifier code shall be reported in MDS 3.0 item S0150. The following method must be used to construct the identifier code. In the first three boxes, enter the first three letters of the resident's last name. In the next six boxes, enter the six digits of the resident's date of birth. Omit the century in the birth date.

(25) "RUG III" is the resource utilization groups, version III system of classifying NF residents into case mix groups described in paragraph (B) of rule 5101:3-3-43.2 of the Administrative Code. Resource utilization groups are clusters of NF residents, defined by resident characteristics, that correlate with resource use.

(26) "Semiannual facility average medicaid case mix score" is the average of a facility's two quarterly facility average medicaid case mix scores. It is used to establish the direct care rate and is calculated pursuant to paragraph (E) of rule 5101:3-3-43.3 of the Administrative Code.

(B) For the purpose of assigning a RUG III classification determining medicaid payment rates for NFs, ODJFS shall utilize the data from the MDS 3.0 as specified by the state and approved by CMS. Each NF shall assess all residents of medicaid-certified beds using the appropriate MDS 3.0 for assessment reference dates (ARDs) on or after October 1, 2010 as set forth in appendix A to this rule for a comprehensive assessment, or appendix D to this rule for a quarterly assessment, or appendix E to this rule for a PPS assessment. When the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) assessment (admission assessment, annual assessment, quarterly assessment, or significant change in status or a significant correction to a prior assessment) and medicare assessment time frames coincide, one assessment shall be used to satisfy both assessments. Admission assessments must be combined with either the medicare five day or medicare fourteen day assessment. For a resident who is not a new admission to the facility, the quarterly, the annual, and significant change in status assessments must be combined with any medicare assessment if the assessment reference date (ARD) is within the assigned medicare observation period. When combining the OBRA and medicare assessments, the most stringent requirement for MDS completion must be met. ODJFS may not utilize the data in the other medicare required assessments (OMRAs) for calculating case mix scores or determining medicaid payment rates.

(1) Comprehensive assessments, medicare-required assessments, quarterly review assessments and significant corrections of quarterly assessments must be conducted in accordance with the requirements and frequency schedule found at 42 C.F.R. 483.20 .

(2) For a comprehensive assessment, NFs must use the Ohio specified MDS 3.0, including section S. The comprehensive assessment, as set forth in appendix A to this rule is completed upon admission, annually, and when a significant change in the resident's status has occurred or a significant correction to a prior comprehensive assessment is required. NFs must use the Ohio specified nursing home quarterly MDS 3.0 as set forth in appendix D to this rule including section S for the quarterly review assessment or a significant correction to a prior quarterly assessment. The nursing home PPS assessment (set forth in appendix E to this rule) must be used for all medicare required assessments.

(3) NFs must use the MDS 3.0 discharge item set as set forth in appendix B to this rule for any residents who transfer, or are discharged and the MDS 3.0 tracking record as set forth in appendix C to this rule for any residents entering or reentering or who died in the facility in accordance with 42 C.F.R. 483.20 .

(4) NFs must use the MDS correction request in section X of the MDS 3.0 for modification or inactivation of MDS records that have been accepted into the national MDS database.

(C) All NFs must submit to the national database encoded, accurate, and complete MDS 3.0 data for all residents of medicaid certified NF beds, regardless of pay source or anticipated length of stay.

(1) MDS 3.0 data completed in accordance with paragraphs (B)(1) to (B)(4) of this rule must be encoded in accordance with 42 C.F.R. 483.20 , CMS' uniform data submission document, and state record layout specifications.

(2) MDS 3.0 data must be submitted in an electronic format and in accordance with the frequency schedule found in 42 C.F.R. 483.20 . The data may be submitted at any time during the reporting quarter that is permitted by instructions issued by the state. Except as provided in paragraph (D) of this rule, all records used in determining the quarterly facility average total case mix score and quarterly facility average medicaid case mix score must be submitted by the filing date.

(3) If a NF submits MDS 3.0 data needed for determining the quarterly facility average total case mix score and quarterly facility average medicaid case mix score after the forty-fifth day after the RPED, ODJFS may assign a quarterly facility average total case mix score as set forth in paragraph (C)(3) of rule 5101:3-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as set forth in paragraph (D)(4) of rule 5101:3-3-43.3 of the Administrative Code.

(4) MDS 3.0 data submitted by a provider that can not be timely extracted by ODJFS from the CMS data server may result in assignment of a quarterly facility average total case mix score as set forth in paragraph (C)(3) of rule 5101:3-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as set forth in paragraph (D)(4) of rule 5101:3-3-43.3 of the Administrative Code.

(5) The annual, semiannual, and quarterly facility average total case mix score and quarterly facility average medicaid case mix score will be calculated using the MDS 3.0 record in effect on the RPED for:

(a) Residents who were admitted to the medicaid certified NF prior to the RPED and continue to be physically present in the NF on the RPED; and

(b) Residents who were admitted to the medicaid certified NF on the RPED;and

(c) Residents who were temporarily absent on the RPED but are considered residents and for whom a return is anticipated from hospital stays, visits with friends or relatives, or participation in therapeutic programs outside the facility.

(6) Records for residents who were permanently discharged from the NF, transferred to another NF, or expired prior to or on the RPED will not be used for determining the quarterly facility average total case mix score and quarterly facility average medicaid case mix score.

(7) For a resident admitted within fourteen days prior to the RPED, and whose initial assessment is not due until after the RPED, both of the following shall apply:

(a) The NF shall submit the appropriate initial assessment as specified in the "Long-Term Care Facility Resident Assessment Instrument User's Manual version 3.0 " issued by CMS (May 2010 http://www.cms.gov/NursingHomeQualityInits/25_NHQIMDS30.asp) and in 42 C.F.R. 483.20 .

(b) The initial assessment, if completed and submitted timely in accordance with paragraphs (C)(1) and (C)(2) of this rule, shall be used for determining the quarterly facility average total case mix score and may be used for determining the quarterly facility average medicaid case mix score in the quarter the resident entered the facility even if the assessment reference date is after the RPED provided the record is identified as a medicaid record pursuant to the calculation methodology in rule 5101:3-3-43.3 of the Administrative Code.

(8) For a resident who had at least one MDS 3.0 assessment completed before being transferred to a hospital, who then reenters the NF within fourteen days prior to the RPED, and has experienced a significant change in status that requires a comprehensive assessment upon reentry, the following shall apply:

(a) The NF shall submit a significant change assessment within fourteen days of reentry, as indicated by the MDS 3.0 assessment reference date (MDS 3.0, item A2300).

(b) The significant change assessment shall be used for determining the quarterly facility average total case mix score and may be used for determining the quarterly facility average medicaid case mix score for the quarter in which the resident reentered the facility even if the assessment reference date is after the RPED provided the record is identified as a medicaid record pursuant to the calculation methodology in rule 5101:3-3-43.3 of the Administrative Code.

(D) Corrections to MDS 2.0 data with an ARD on or before September 30, 2010 must be made in accordance with the requirements in the "CMS Revised Long Term Care Resident Assessment Instrument User's Manual version 2.0 ", and the "State Operations Manual" issued by CMS (http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none &filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS1201984 &intNumPerPage=10). Corrections to MDS 3.0 data with an ARD on or after October 1, 2010 must be made in accordance with the requirements in the "Long-Term Care Facility Resident Assessment Instrument User's Manual version 3.0 ", and the "State Operations Manual" issued by CMS (Rev.1, May 21, 2004 http://www.cms.gov/Manuals/IOM/).

(1) For use in determining the quarterly facility average total case mix score and quarterly facility average medicaid case mix score, the facility must transmit the corrections to the national database no later than forty-five days after the RPED.

(2) For use in determining the quarterly facility average total case mix score and quarterly facility average medicaid case mix score, all significant correction assessments must contain an assessment reference date within the reporting quarter.

(3) The provider shall submit an accurate, encoded MDS 2.0 record for an ARD on or before September 30, 2010, or an accurate, encoded MDS 3.0 record for an ARD on or after October 1, 2010 for each resident in a medicaid certified bed on the RPED.

(a) The provider shall transmit MDS assessments that were completed timely but omitted from the previous transmissions and ODJFS shall use the resident case mix scores from the assessments for determining the quarterly facility average total case mix score and may be used for determining the quarterly facility average medicaid case mix score, if the assessments are transmitted no later than forty-five days after the RPED provided the record is identified as a medicaid record pursuant to the calculation methodology in rule 5101:3-3-43.3 of the Administrative Code. If the assessments are not transmitted within forty-five days after the RPED, ODJFS may assign a default group for those records.

(b) The provider shall notify ODJFS within forty-five days of the RPED of any records for residents in medicaid certified beds on the RPED that were not completed timely and were not transmitted to the national database. ODJFS may assign default scores to those records as described in paragraph (F) of rule 5101:3-3-43.2 of the Administrative Code.

(c) The provider has forty-five days after the RPED to transmit the appropriate discharge assessment to the national database, if more residents are determined as being in the facility on the RPED than the number of its medicaid certified beds. If the facility does not correct the error within forty-five days after the RPED, ODJFS may assign a quarterly facility average total case mix score as specified in paragraph (C)(3) of rule 5101:3-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as specified in paragraph (D)(4) of rule 5101:3-3-43.3 of the Administrative Code.

(d) The provider shall notify ODJFS within forty-five days of the RPED of any residents who were reported to be residents of the facility on the RPED, but who had actually been discharged prior to the RPED. If the provider fails to correct the error within forty-five days after the RPED, ODJFS may assign a quarterly facility average total case mix score as specified in paragraph (C)(3) of rule 5101:3-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as specified in paragraph (D)(4) of rule 5101:3-3-43.3 of the Administrative Code.

(e) The provider has forty-five days after the RPED to submit appropriate modifications or discharge assessments to rectify any discrepancy between the records selected for determining the quarterly facility average total case mix score and the facility census on the RPED. If the facility does not correct the error(s) within forty-five days after the RPED, ODJFS may assign a quarterly facility average total case mix score as specified in paragraph (C)(3) of rule 5101:3-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as specified in paragraph (D)(4) of rule 5101:3-3-43.3 of the Administrative Code.

(4) If the provider's number of records assigned to the default group in accordance with paragraphs (D)(3)(a) and (D)(3)(b) of this rule is greater than ten per cent, ODJFS may assign a quarterly facility average total case mix score as specified in paragraph (C)(3) of rule 5101:3-3-43.3 of the Administrative Code and a quarterly facility average medicaid case mix score as specified in paragraph (D)(4) of rule 5101:3-3-43.3 of the Administrative Code.

Replaces: 5101:3-3- 43.1

Click to view Appendix

Click to view Appendix

Click to view Appendix

Click to view Appendix

Click to view Appendix

Click to view Appendix

Click to view Appendix

Click to view Appendix

Click to view Appendix

Click to view Appendix

Effective: 10/01/2010
R.C. 119.032 review dates: 10/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.232
Prior Effective Dates: 10/1/92 (Emer.), 12/31/92, 4/15/93 (Emer.), 7/1/93, 12/1/93 (Emer.), 3/17/94, 7/1/94 (Emer.), 9/30/94, 7/1/98, 10/1/00, 1/8/04, 7/1/05, 2/2/06, 7/1/06, 10/1/06, 4/3/10

5160-3-43.2 Resource utilization groups, version III (RUG III): the nursing facility case mix payment system.

The Ohio department of job and family services (ODJFS) shall pay each eligible nursing facility (NF) provider a per resident per day rate for direct care costs established prospectively for each facility. The department shall establish each provider's rate for direct care costs semiannually. Each provider's rate for direct care costs shall be based on a case mix payment system.

(A) The Ohio medicaid case mix payment system for direct care contains the following core components:

(1) As set forth in rule 5101:3-3-43.1 of the Administrative Code, a uniform resident assessment instrument (the minimum data set version 3.0, (MDS 3.0 ) including section S) and as set forth in appendix A to this rule, a database which provides the core data elements that are used to group residents into case mix categories;

(2) A methodology for grouping residents into case mix groups in a way that is clinically meaningful and uses criteria that sufficiently differentiates one group from another, as outlined in paragraphs (B) to (F) of this rule;

(3) The identification of those specific costs within the direct care cost category which will be affected by changes in case mix, as described in paragraph (G) of this rule.

(4) A means of measuring the relative costliness of caring for residents in one group versus another, known as "relative resource weights", as described in paragraph (H) of this rule.

(B) The medicaid provider case mix payment system shall use the methodology for grouping residents known as RUG III developed through the United States centers for medicare and medicaid services (CMS) multistate nursing home case-mix and quality demonstration project and described in this rule. Residents in each RUG III group utilize similar quantities and patterns of resources. The RUG III categories are listed in descending order of hierarchy. Based on the items in the MDS 3.0, if a resident meets the criteria for placement in more than one group, the resident will be placed in a group within the highest major category of resident types according to the hierarchy unless the activities of daily living (ADL) index score is not met for placement within the highest major category of resident types. The RUG III classification system includes the following seven mutually exclusive major categories of resident types from which forty-four RUG III groups are classified:

(1) Extensive care, which includes three groups;

(2) Special rehabilitation, which includes five resident subtypes and fourteen groups;

(3) Special care, which includes three groups;

(4) Clinically complex, which includes six groups;

(5) Impaired cognition, which includes four groups;

(6) Behavior problems, which includes four groups; and

(7) Reduced physical functioning, which includes ten groups. Residents without any of the characteristics which result in assignment to the higher categories comprise the last resident type.

(C) The RUG III classification system defines the criteria that are used to assign residents into one of the seven major categories of resident types. These criteria are summarized in paragraph (D) of this rule. Assignment of a resident to one of the RUG III groups within the major category is then based upon either or both of the following additional dimensions described below: resident functionality as measured by an ADL index score outlined in paragraph (C)(1) of this rule and additional problems or services required, outlined in paragraphs (C)(2) and (C)(3) of this rule.

(1) With the exception of the extensive care category, each group within a major category of resident types is identified by an ADL index score, which is computed using a special scoring technique. The ADL index score is based on four ADL variables (bed mobility, toileting, transfer and eating) and is calculated by assigning a score for the resident on each ADL variable and summing the scores. A resident's ADL index score may range from four to eighteen.

(a) The ADL scores for bed mobility, toileting, and transfer are as follows:

(i) On the MDS 3.0 at section G: functional status, ADL self performance, items (G0110A1), (G0110B1), and (G0110I1), residents coded with a "-" for unknown, "0" for independent, "1" for supervision, or "7" for activity occurred only once or twice are assigned an ADL score of one for each ADL activity.

(ii) On the MDS 3.0 at section G: functional status, ADL self performance, items (G0110A1), (G0110B1), and (G0110I1), residents coded with "2" for limited assistance are assigned an ADL score of three in each ADL activity.

(iii) On the MDS 3.0 at section G: functional status, ADL self performance, items (G0110A1), (G0110B1), and (G0110I1), residents coded with "3" for extensive assistance, "4" for total dependence or "8" for "activity did not occur during entire 7 days" are assigned an ADL score of four in each ADL activity if they are coded on MDS 3.0 item (G0110A2), (G0110B2), or (G0110I2), respectively, as "-" for unknown, "0" for no set up or physical help from staff, "1" for setup help only, or "2" for "one person physical assist".

(iv) On the MDS 3.0 at section G: functional status, ADL self performance, items (G0110A1), (G0110B1), and (G0110I1), residents coded with "3" for "extensive assistance," "4" for "total dependence," or "8" for "activity did not occur during entire 7 days" are assigned an ADL score of five in each ADL activity if they are coded on ADL support provided item (G0110A2), (G0110B2), or (G0110I2), respectively, as "3" for "two+ persons physical assist" or "8" for "ADL activity itself did not occur during entire period".

(b) The ADL score for eating is as follows:

(i) On the MDS 3.0 at section G: functional status, ADL self performance, item (G0110H1), residents coded with a "-" for unknown, "0" for independent, "1" for supervision, or "7" for activity occurred only once or twice are assigned an ADL score of one.

(ii) On the MDS 3.0 at section G: functional status, ADL self performance, item (G0110H1), residents coded with "2" for limited assistance are assigned an ADL score of two.

(iii) On the MDS 3.0 at section G: functional status, ADL self performance, item (G0110H1), residents coded with "3" for "extensive assistance", "4" for "total dependence" or "8" for "activity did not occur during entire 7 days" are assigned an ADL score of three. This score is also assigned if section K: swallowing/nutritional status, item (K0500A) for "parenteral/IV feeding" is checked. This score is also assigned if item (K0500B) for "feeding tube" is checked and if fifty-one per cent or more of total calories are received through parenteral or tube feeding, item (K0700A) is coded "3", or twenty-six per cent to fifty per cent of total calories received through parenteral or tube feeding, item (K0700A) is coded "2", and fluid intake is five hundred one or more cubic centimeters (CCs) per day, item (K0700B) is coded "2".

(2) Symptoms of depression are used to determine groupings for those who qualify for the clinically complex category using the criteria outlined in paragraph (D)(6) of this rule.

(a) On the MDS 3.0 at section D: mood, "Should Resident Mood Interview be Conducted," item (D0100), for residents coding yes "1", the assessor will attempt to complete the interview. If the assessor is unable to complete the interview or if item D0100 is coded "0" no, the assessor will complete the "Staff Assessment of Resident Mood" (PHQ-9-OV©), item (D0500).

(b) The resident is assessed with symptoms of depression if a total severity score is greater than or equal to ten but not ninety-nine coded on the MDS 3.0 at section D: mood, total severity score, item (D0300).

(c) The total severity score is the sum of the frequency of the following symptoms on the MDS 3.0 section D: mood, resident mood interview (PHQ-9©), item (D0200):

(i) Little interest or pleasure in doing things (on MDS 3.0 at section D: mood, item (D0200A2)).

(ii) Feeling down, depressed, or hopeless (on MDS 3.0 at section D: mood, item (D0200B2)).

(iii) Trouble falling or staying asleep, or sleeping too much (on MDS 3.0 at section D: mood, item (D0200C2)).

(iv) Feeling tired or having little energy (on MDS 3.0 at section D: mood, item (D0200D2)).

(v) Poor appetite or overeating (on MDS 3.0 at section D: mood, item (D0200E2)).

(vi) Feeling bad about yourself-or that you are a failure or have let yourself or your family down (on MDS 3.0 at section D: mood, item (D0200F2)).

(vii) Trouble concentrating on things, such as reading the newspaper or watching television (on MDS 3.0 at section D: mood, item (D0200G2)).

(viii) Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual (on MDS 3.0 at section D: mood, item (D0200H2)).

(ix) Thoughts that you would be better off dead, or of hurting yourself in some way (on MDS 3.0 at section D: mood, item (D0200I2)).

(d) If the "Resident Mood Interview" (PHQ-9©) is not successfully completed, the staff assessment of resident mood (PHQ-9-OV©) on the MDS 3.0 section D: mood, item (D0500) is used to determine grouping for those who qualify for the clinically complex resource utilization group using the criteria outlined in paragraph (D)(6) of this rule.

(e) The resident is assessed with symptoms of depression if a total severity score is greater than or equal to ten coded (on the MDS 3.0 at section D: mood, item (D0600)). The total severity score is the sum of the frequency of the following symptoms:

(i) Little interest or pleasure in doing things (on the MDS 3.0 section D: mood, item (D0500A2)).

(ii) Feeling or appearing down, depressed, or hopeless (on the MDS 3.0 section D: mood, item (D0500B2)).

(iii) Trouble falling or staying asleep, or sleeping too much (on the MDS 3.0 section D: mood, item (D0500C2)).

(iv) Feeling tired or having little energy (on the MDS 3.0 section D: mood, item (D0500D2)).

(v) Poor appetite or overeating (on the MDS 3.0 section D: mood, item (D0500E2)).

(vi) Indicating that s/he feels bad about self, is a failure, or has let self or family down (on the MDS 3.0 section D: mood, item (D0500F2)).

(vii) Trouble concentrating on things, such as reading the newspaper or watching television (on the MDS 3.0 section D: mood, item (D0500G2)).

(viii) Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that s/he has been moving around a lot more than usual (on the MDS 3.0 section D: mood, item (D0500H2)).

(ix) States that life isn't worth living, wishes for death, or attempts to harm self (on the MDS 3.0 section D: mood, item (D0500I2)).

(x) Being short-tempered, easily annoyed (on the MDS 3.0 section D: mood, item (D0500J2)).

(3) Restorative nursing programs, current toileting program or trial, and/or bowel toileting program are used to determine grouping within three categories of resident types which are impaired cognition, behavior problems, and reduced physical function and in classifying residents into the low intensity resident subtype of the rehabilitation category.

(a) Two or more of the following activities, each occurring within the timeframes described in paragraph (C)(3)(b) of this rule places an individual in a higher resource use group within the impaired cognition, behavior problems, or reduced physical functioning categories and in classifying residents into the low intensity resident subtype of the rehabilitation category:

(i) Passive range of motion and/or active range of motion (on the MDS 3.0 at section O: special treatments, procedures, and programs, restorative nursing programs, item (O0500A) or (O0500B));

(ii) Splint or brace assistance (on the MDS 3.0 at section O: special treatments, procedures, and programs, restorative nursing programs, item (O0500C));

(iii) Training and skill practice in any of the following:

(a)Walking and/or bed mobility (on the MDS 3.0 at section O:special treatments, procedures, and programs, restorative nursing programs, item (O0500F) or (O0500D)),

(b)Transfer (on the MDS 3.0, at section O: special treatments, procedures, and programs, restorative nursing programs, item (O0500E)),

(c)Dressing and/or grooming (on the MDS 3.0 at section O:special treatments, procedures, and programs, restorative nursing programs, item (O0500G)),

(d)Eating and/or swallowing (on the MDS 3.0 at section O:special treatments, procedures, and programs, restorative nursing programs, item (O0500H)),

(e)Amputation/prostheses care (on the MDS 3.0 at section O:special treatments, procedures, and programs, restorative nursing programs, item (O0500I)),

(f)Communication (on the MDS 3.0 at section O: special treatments, procedures, and programs, restorative nursing programs, item (O0500J)),

(iv) Current toileting program or trial, and/or bowel toileting program (on the MDS 3.0 at section H: bladder and bowel, item (H0200C) or (H0500)). The current toileting program or trial at item (H0200C) must be managed four or more days of the seven day look back period.

(b) Each restorative nursing program must be performed at least six days a week for at least fifteen minutes a day to be counted. The current toileting program or trial at item (H0200C) must be managed four or more days of the seven day look back period.

(D) The RUG III criteria for classification into the seven major categories and the forty-four groups is listed below:

(1) The extensive care category includes residents who have a RUG III ADL index score of seven through eighteen and is determined by the two sets of qualifiers set forth in paragraphs (D)(1)(a) and (D)(1)(b) of this rule.

(a) The presence of extensive treatments received are the initial qualifiers for the extensive care category. The following clinical indicators are the initial qualifiers. If the initial qualifiers are met but the ADL index score is four, five or six the record shall be placed in the special care category SSA.

(i) Parenteral/IV feeding (on the MDS 3.0 at section K: swallowing/nutritional status, item (K0500A)),

(ii) Suctioning, including nasopharyngeal or tracheal aspiration (on the MDS 3.0 at section O: special treatments, procedures, and programs, items (O0100D1 "while NOT a resident") and/or (O0100D2 "while a resident")),

(iii) Tracheostomy care (on the MDS 3.0 at section O: special treatments, procedures, and programs, items (O0100E1 "while NOT a resident") and/or (O0100E2 "while a resident")),

(iv) Ventilator or respirator (on the MDS 3.0 at section O: special treatments, procedures, and programs, items (O0100F1 "while NOT a resident") and/or (O0100F2 "while a resident")), and

(v) IV medications (on the MDS 3.0 at section O: special treatments, procedures, and programs, items (O0100H1 "while NOT a resident") and/or (O0100H2 "while a resident")).

(b) Once the resident has qualified for the extensive care category, a secondary set of qualifiers determines the RUG III grouping. The qualifiers are:

(i) Parenteral/IV feeding (on the MDS 3.0 at section K: swallowing/nutritional status, item (K0500A)),

(ii) IV medications (on the MDS 3.0 at section O: special treatments, procedures, and programs, items (O0100H1 "while NOT a resident) and/or (O0100H2 "while a resident")),

(iii) Eligible for special care (as described in paragraph (D)(4) of this rule,

(iv) Eligible for clinically complex (as described in paragraph (D)(6) of this rule) or

(v) Eligible for impaired cognition (as described in paragraph (D)(8) of this rule.

(2) The extensive care category has three groups of residents who meet one or more of the secondary extensive qualifiers listed in paragraph (D)(1) of this rule:

(a) Class "SE3" residents are in RUG III group one and meet four or five of the secondary qualifiers.

(b) Class "SE2" residents are in RUG III group two and meet two or three of the secondary qualifiers.

(c) Class "SE1" residents are in RUG III group three and meet zero or one of the secondary qualifiers.

(3) The special rehabilitation category is split into five resident subtypes and has fourteen groups. Therapies refers to any combination of physical therapy, occupational therapy, or speech-language pathology and audiology services. On the MDS 3.0, at section O: special treatments, procedures, and programs, items (O0400A4), (O0400B4), and (O0400C4), the number of days each type of therapy is administered for fifteen minutes or more in the last seven calendar days is recorded. On the MDS 3.0, at section O: special treatments, procedures, and programs, items (O0400A1 through O0400A3), (O0400B1 through O0400B3), and (O0400C1 through O0400C3), the total number of minutes each type of therapy is provided for individual, concurrent, and group therapy in the last seven days is recorded.

(a) Ultra high intensity multidisciplinary rehabilitation is the first subtype for residents who receive:

(i) Seven hundred twenty minutes or more of any combination of rehabilitation therapy per week; and

(ii) At least one type of therapy for five or more days per week and at least fifteen minutes per day; and

(iii) At least one type of therapy three or more days per week and at least fifteen minutes per day.

(b) The ultra high intensity rehabilitation subtype has three groups:

(i) Class "RUC" residents are in RUG III group four and have an ADL index score of sixteen to eighteen.

(ii) Class "RUB" residents are in RUG III group five and have an ADL index score of nine through fifteen.

(iii) Class "RUA" residents are in RUG III group six and have an ADL index score of four through eight.

(c) Very high intensity rehabilitation is the second subtype for residents who receive:

(i) Five hundred minutes or more of any combination of rehabilitation therapy per week; and

(ii) At least one type of therapy for five or more days per week and at least fifteen minutes per day.

(d) The very high intensity rehabilitation subtype has three groups.

(i) Class "RVC" residents are in RUG III group seven and have an ADL index score of sixteen through eighteen.

(ii) Class "RVB" residents are in RUG III group eight and have an ADL index score of nine through fifteen.

(iii) Class "RVA" residents are in RUG III group nine and have an ADL index score of four through eight.

(e) High intensity rehabilitation is the third subtype for residents who receive:

(i) Three hundred twenty-five minutes or more of any combination of rehabilitation therapy per week; and

(ii) At least one type of therapy for five or more days per week and at least fifteen minutes per day.

(f) The high intensity rehabilitation subtype has three groups.

(i) Class "RHC" residents in RUG III group ten have an ADL index score of thirteen through eighteen.

(ii) Class "RHB" residents in RUG III group eleven have an ADL index score of eight through twelve.

(iii) Class "RHA" residents in RUG III group twelve have an ADL index score of four through seven.

(g) Medium intensity rehabilitation is the fourth subtype for residents who receive:

(i) One hundred fifty minutes or more of any combination of rehabilitation therapy per week; and

(ii) At least five days per week of any combination of rehabilitation therapy.

(h) The medium intensity rehabilitation subtype has three groups.

(i) Class "RMC" residents in RUG III group thirteen have an ADL index score of fifteen through eighteen.

(ii) Class "RMB" residents in RUG III group fourteen have an ADL index score of eight through fourteen.

(iii) Class "RMA" residents in RUG III group fifteen have an ADL index score of four through seven.

(i) Low intensity rehabilitation is the fifth subtype for residents who receive the following:

(i) Forty-five minutes or more of any combination of rehabilitation therapy per week; and

(ii) At least three days per week of any combination of rehabilitation therapy; and

(iii) At least two types of restorative nursing programs each provided at least six days per week, current toileting program or trial managed for four or more days of the seven days, or bowel toileting program. Programs counted for the rehabilitation category are listed in paragraphs (C)(3)(a)(i) to (C)(3)(a)(iv) of this rule.

(j) The low intensity rehabilitation subtype has two groups.

(i) Class "RLB" residents in RUG III group sixteen have an ADL index score of fourteen through eighteen.

(ii) Class "RLA" residents in RUG III group seventeen have an ADL index score of four through thirteen.

(4) Except as set forth in paragraph (D)(4)(d) of this rule, the special care category includes residents who have a RUG III ADL index score of seven through eighteen and either:

(a) Have one or more of the following conditions:

(i) Cerebral palsy (on the MDS 3.0 at section I: active diagnoses, item (I4400)), with an ADL index score greater than or equal to ten;

(ii) Surgical wound(s) or open lesion(s) other than ulcers, rashes, cuts (on the MDS 3.0 at section M: skin conditions, item (M1040E) or (M1040D)) and surgical wound care (on the MDS 3.0 at section M: skin conditions, item (M1200F)) or application of nonsurgical dressings with or without topical medications other than to feet or application of ointments/medications other than to feet (on the MDS 3.0 section M: skin conditions, items (M1200G or M1200H));

(iii) Fever with vomiting, pneumonia, weight loss, dehydrated, or feeding tube with percent intake by artificial route qualifiers. On the MDS 3.0 at section J: health conditions, item (J1550A) is checked and at least one of the following: At section J: item (J1550B) is checked, or at section I: active diagnoses item (I2000) is checked, or at section K: weight loss, item (K0300) is scored "1" or "2", or at section J: health conditions item (J1550C) is checked or at section K: swallowing/nutritional status, item (K0500B) is checked and fifty-one per cent or more of total calories are received through parenteral or tube feeding intake (item (K0700A) is coded "3") or twenty-six per cent to fifty per cent of total calories received through parenteral or tube feeding intake (item (K0700A) is coded "2") and fluid intake is five hundred one or more cubic centimeters (CCs) per day item (K0700B) is coded "2";

(iv) Multiple sclerosis (on the MDS 3.0 at section I: active diagnoses, item (I5200)) with an ADL index score greater than or equal to ten;

(v) Stage three or four pressure ulcer or unstageable pressure ulcer-slough and/or eschar (on the MDS 3.0 at section M: skin conditions, items (M0300C1), (M0300D1), or (M0300F1)) and two or more selected skin and ulcer treatments (on the MDS 3.0 at section M: skin conditions, items (M1200A), pressure reducing device for chair, or (M1200B) pressure reducing device for bed, (M1200C) turning/repositioning program, (M1200D) nutrition or hydration intervention to manage skin problems, (M1200E) ulcer care, (M1200G) application of nonsurgical dressings (with or without topical medications) other than to feet or (M1200H) application of ointments/medications other than to feet) or two or more ulcers of any type (on the MDS 3.0 at section M: skin conditions, item (M0300A), (M0300B1), (M0300C1), (M0300D1), (M0300F1), or (M1030) number of venous and arterial ulcers and two or more selected skin and ulcer treatments (on the MDS 3.0 at section M: skin conditions, item (M1200A), pressure reducing device for chair, or (M1200B) pressure reducing device for bed, (M1200C) turning/repositioning program, (M1200D) nutrition or hydration intervention to manage skin problems, (M1200E) ulcer care, (M1200G) application of nonsurgical dressings (with or without topical medications) other than to feet or (M1200H) application of ointments/medications other than to feet);

(vi) Quadriplegia (on the MDS 3.0 at section I: active diagnoses, item (I5100)), with an ADL index score greater than or equal to ten; or

(b) Receive one or more of the following types of special care:

(i) Seven days of respiratory therapy (on the MDS 3.0 at section O: special treatments, procedures, and programs, item (O0400D2)),

(ii) Radiation treatment (on the MDS 3.0 at section O: special treatments, procedures, and programs, items (O0100B1 "while NOT a resident") and/or (O0100B2 "while a resident)), or

(iii) Feeding tube (on the MDS 3.0 at section K: swallowing/nutritional status, item (K0500B)) with parenteral or tube feeding intake (on the MDS 3.0 at section K: parenteral or tube feeding intake item (K0700A) is coded "3" or item (K0700A) is coded "2" and item (K0700B) is coded "2" and aphasia (on the MDS 3.0 section I, active diagnoses, item (I4300)).

(c) Meet the conditions for the extensive care category but have a RUG III ADL index score of four, five, or six.

(d) If the ADL index score is four, five or six the record shall be placed in the clinically complex category CA1.

(5) The special care category has three groups.

(a) Class "SSC" residents in RUG III group eighteen have an ADL index score of seventeen through eighteen.

(b) Class "SSB" residents in RUG III group nineteen have an ADL index score of fifteen through sixteen.

(c) Class "SSA" residents in RUG III group twenty have an ADL index score of seven through fourteen.

(6) The clinically complex category includes residents who have at least one of the following conditions or are receiving at least one of the following treatments:

(a) Burns (on the MDS 3.0 at section M; skin conditions, item (M1040F)),

(b) Comatose (on the MDS 3.0 at section B: hearing, speech, and vision, item (B0100) is scored "1", and at section G: functional status, ADL self performance, items (G0110A1), (G0110B1), (G0110H1), and (G0110I1) are scored "4" for total dependence or "8" for activity did not occur during entire seven days).

(c) Diabetes mellitus (on the MDS 3.0 at section I: active diagnoses, item (I2900)) and injections on seven days (on the MDS 3.0 at section N: medications, item (N0300)) and physician order changes on two or more days (on the MDS 3.0 at section O: special treatments, procedures, and programs, item (O0700)).

(d) Dehydrated (on the MDS 3.0 at section J: health conditions, item (J1550C)),

(e) Hemiplegia or hemiparesis (on the MDS 3.0 at section I: active diagnoses, item (I4900)), with an ADL index score greater than or equal to ten,

(f) Internal bleeding (on the MDS 3.0 at section J: health conditions, item (J1550D)),

(g) Pneumonia (on the MDS 3.0 at section I: active diagnoses, item (I2000)),

(h) Infection of the foot, diabetic foot ulcer(s) or other open lesion(s) on the foot (on the MDS 3.0 at section M: skin conditions, items (M1040A), (M1040B) or (M1040C)) and application of dressings to feet (with or without topical medications) (on the MDS 3.0 at section M: skin conditions, item (M1200I)),

(i) Septicemia (on the MDS 3.0 at section I: active diagnoses, item (I2100)),

(j) Feeding tube (on the MDS 3.0 at section K: swallowing/nutritional status, item (K0500B)) and fifty-one per cent or more of total calories are received through parenteral or tube feeding intake, item (K0700A) is coded "3" or twenty-six per cent to fifty per cent of total calories received through parenteral or tube feeding, item (K0700A) is coded "2" and fluid intake is five hundred one or more cubic centimeters (CCs) per day, item (K0700B) is coded "2",

(k) Chemotherapy (on the MDS 3.0 at section O: special treatments, procedures, and programs, items (O0100A1 "while NOT a resident") and/or (O0100A2 "while a resident")),

(l) Dialysis (on the MDS 3.0 at section O: special treatments, procedures, and programs, items (O0100J1 "while NOT a resident") and/or (O0100J2 "while a resident")),

(m) Physician order changes on four or more days in the last fourteen days (on the MDS 3.0 at section O: special treatments, procedures, and programs, item (O0700)) and physician examinations of one or more days (on the MDS 3.0 at section O: special treatments, procedures, and programs, item (O0600) or physician order changes on two or more days (on the MDS 3.0 at section O: special treatments, procedures, and programs, item (O0700)) and physician examinations on two or more days (on the MDS 3.0 section O: special treatments, procedures, and programs, item (O0600)),

(n) Oxygen therapy (on the MDS at section O: special treatments, procedures, and programs, items (O0100C1 "while NOT a resident") and/or (O0100C2 "while a resident")),

(o) Transfusions (on the MDS 3.0 at section O: special treatments, procedures, and programs, items (O0100I1 "while NOT a resident") and/or (O0100I2 "while a resident")),

(p) Meet the conditions for the special care categories but have a RUG III ADL index score of four, five or six.

(7) The clinically complex category has six groups.

(a) Class "CC2" residents in RUG III group twenty-one have an ADL index score of seventeen through eighteen and have symptoms of depression as described in paragraph (C)(2) of this rule.

(b) Class "CC1" residents in RUG III group twenty-two have an ADL index score of seventeen through eighteen and do not have symptoms of depression as described in paragraph (C)(2) of this rule.

(c) Class "CB2" residents in RUG III group twenty-three have an ADL index score of twelve through sixteen and have symptoms of depression as described in paragraph (C)(2) of this rule.

(d) Class "CB1" residents in RUG III group twenty-four have an ADL index score of twelve through sixteen and do not have symptoms of depression as described in paragraph (C)(2) of this rule.

(e) Class "CA2" residents in RUG III group twenty-five have an ADL index score of four through eleven and have symptoms of depression as described in paragraph (C)(2) of this rule.

(f) Class "CA1" residents in RUG III group twenty-six have an ADL index score of four through eleven and do not have symptoms of depression as described in paragraph (C)(2) of this rule.

(8) The impaired cognition category includes residents with a RUG III ADL index score of four through ten, and a "Brief Interview for Mental Status" (BIMS) score less than or equal to nine or a cognitive performance scale of three through six. The BIMS score ranges from zero to fifteen and is based on resident responses to seven questions. On the MDS 3.0 at section C: cognitive patterns, "Should Brief Interview for Mental Status" be conducted, item (C0100), for residents coding yes "1", the assessor will attempt to complete the BIMS. If coded "0" no, the cognitive performance scale described in paragraph (D)(8)(b) of this rule is computed to determine impaired cognition.

(a) The BIMS is based on 3 qualifiers: repetition of three words, temporal orientation, and recall. The summation of the following qualifiers on the MDS 3.0 at section C: cognitive patterns, summary score, item (C0500) determine the BIMS score for the impaired cognition category:

(i) Repetition of three words (on the MDS 3.0 at section C: cognitive patterns, item (C0200)),

(ii) Able to report correct year (on the MDS 3.0 at section C: cognitive patterns, item (C0300A)),

(iii) Able to report correct month (on the MDS 3.0 at section C: cognitive patterns, item (C0300B)),

(iv) Able to report correct day of week (on the MDS 3.0 at section C: cognitive patterns, item (C0300C)),

(v) Able to recall "sock" (on the MDS 3.0 at section C: cognitive patterns, item (C0400A)),

(vi) Able to recall "blue" (on the MDS 3.0 at section C: cognitive patterns, item (C0400B)),

(vii) Able to recall "bed" (on the MDS 3.0 at section C: cognitive patterns, item (C0400C)).

(b) If the BIMS cannot be completed, the cognitive performance scale is computed to determine impaired cognition. The cognitive performance scale values range from zero to six and are based on three qualifiers: the presence or absence of coma, self-performance in eating and the summation of an impairment count and a severity count which evaluates the resident using the MDS 3.0 variables. These three qualifiers, evaluated in the following manner, determine the resident's cognitive performance scale for the impaired cognition category:

(i) On the MDS 3.0 at section B: hearing, speech, and vision, item (B0100) residents coded with a "one" for comatose, section G: functional status-ADL self performance, items (G0110A1), (G0110B1), (G0110H1), and (G0110I1) are scored "4" for total dependence or "8" for activity did not occur during entire seven days, and in section C: cognitive patterns, cognitive skills for daily decision making item (C1000) is not coded "-", "0", "1" or "2", the cognitive performance scale is assigned a score of six.

(ii) On the MDS 3.0 at section C: cognitive patterns, cognitive skills for daily decision making item (C1000), residents coded with a "3" for severely impaired and section G: functional status, ADL self-performance, eating item (G0110H1), is coded "4" for total dependence or "8" for activity did not occur during entire seven days, the cognitive performance scale is assigned a score of six. If section G, eating item (G0110H1) is coded "-" for unknown, "0" for independent, "1" for supervision, "2" for limited assistance, or "3" for extensive assistance, the cognitive performance scale is assigned a score of five.

(iii) The summation of the impairment count and severity count are used in assigning values of one through four on the cognitive performance scale and are calculated as follows:

(a) The impairment count identifies deficits in three key cognitive areas and is determined by summing the scores for the following variables:

(i) Short term memory, on the MDS 3.0 at section C: cognitive patterns, item (C0700) residents coded "1" for a memory problem are assigned a score of one.

(ii) Cognitive skills for daily decision making, on the MDS 3.0 at section C: cognitive patterns, item (C1000), residents coded with a "1" for modified independence or "2" for moderately impaired are assigned a score of one.

(iii) Makes self understood, on the MDS 3.0 at section B: hearing, speech, and vision, item (B0700), residents coded "1" for usually understood, "2" for sometimes understood or "3" for rarely/never understood are assigned a score of one.

(b)The severity count identifies the deficit level of residents with moderate to severe impairment in cognitive skills for daily decision making (C1000) and in makes self understood (B0700). This count is determined by summing the scores for the following variables:

(i) On the MDS 3.0 at section C: cognitive patterns, cognitive skills for daily decision making, item (C1000), residents coded with a "2" for moderately impaired are assigned a score of one.

(ii) On the MDS 3.0 at section B: hearing, speech, and vision, makes self understood, item (B0700), residents coded with "2" for sometimes understood or "3" for rarely/never understood are assigned a score of one.

(c)If the total for the impairment count is two or three and the total for the severity count is two, the cognitive performance scale is assigned a score of four.

(d)If the total for the impairment count is two or three and the total for the severity count is one, the cognitive performance scale is assigned a score of three.

(e)If the total for the impairment count is two or three and the total of the severity count is zero, the cognitive performance scale is assigned a score of two. Residents would not qualify for the impaired cognition category.

(f)If the total of the impairment count is one, the cognitive performance scale is assigned a score of one. Residents would not qualify for the impaired cognition category.

(9) The impaired cognition category has four groups.

(a) Class "IB2" residents in RUG III group twenty-seven have an ADL index score of six through ten and receive two or more restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(b) Class "IB1" residents in RUG III group twenty-eight have an ADL index score of six through ten and receive only one or no restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(c) Class "IA2" residents in RUG III group twenty-nine, have an ADL index score of four through five and receive two or more restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(d) Class "IA1" residents in RUG III group thirty have an ADL index score of four through five and receive only one or no restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(10) The behavior problems category includes residents with a RUG III ADL index score of four through ten, and

(a) Have hallucinations and/or delusions (on the MDS 3.0 at section E:behavior, items (E0100A) or (E0100B)), or

(b) Problem displayed in any one of the following on four or more days per week:

(i) Wandering (on the MDS 3.0 at section E: behavior, item (E0900)), or

(ii) Verbal behavioral symptoms directed toward others (on the MDS 3.0 at section E: behavior, item (E0200B)), or

(iii) Physical behavioral symptoms directed toward others (on the MDS 3.0 at section E: behavior, item (E0200A)), or

(iv) Other behavioral symptoms not directed toward others (on the MDS 3.0 at section E: behavior, item (E0200C)), or

(v) Rejection of care (on the MDS 3.0 at section E: behavior, item (E0800)).

(11) The behavior problems category has four groups.

(a) Class "BB2" residents in RUG III group thirty-one have an ADL index score of six through ten and receive two or more restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(b) Class "BB1" residents in RUG III group thirty-two have an ADL index score of six through ten and receive only one or no restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(c) Class "BA2" residents in RUG III group thirty-three have an ADL index score of four through five and receive two or more restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(d) Class "BA1" residents in RUG III group thirty-four have an ADL index score of four through five and receive only one or no restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(12) The reduced physical function category has ten groups and includes residents who do not meet the conditions of any of the previous categories, including those who would meet the criteria for the impaired cognition or behavior problems categories but have a RUG III ADL index score of more than ten.

(a) Class "PE2" residents in RUG III group thirty-five have an ADL index score of sixteen through eighteen and receive two or more restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(b) Class "PE1" residents in RUG III group thirty-six have an ADL index score of sixteen through eighteen and receive only one or no restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(c) Class "PD2" residents in RUG III group thirty-seven have an ADL index score of eleven through fifteen and receive two or more restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(d) Class "PD1" residents in RUG III group thirty-eight have an ADL index score of eleven through fifteen and receive only one or no restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(e) Class "PC2" residents in RUG III group thirty-nine have an ADL index score of nine or ten and receive two or more restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(f) Class "PC1" residents in RUG III group forty have an ADL index score of nine or ten and receive only one or no restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(g) Class "PB2" residents in RUG III group forty-one have an ADL index score of six through eight and receive two or more restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(h) Class "PB1" residents in RUG III group forty-two have an ADL index score of six through eight and receive only one or no restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(i) Class "PA2" residents in RUG III group forty-three have an ADL index score of four or five and receive two or more restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(j) Class "PA1" residents in RUG III group forty-four have an ADL index score of four or five and receive only one or no restorative nursing programs six days or more per week, current toileting program or trial managed four or more days or bowel toileting program as described in paragraph (C)(3) of this rule.

(E) A list of the MDS 3.0 data elements used to group residents in the RUG III classification system is set forth in appendix A to this rule. The ADL index scoring system is set forth in a table in appendix B to this rule. A description of classification branches in the RUG III system is summarized in the table set forth in appendix C to this rule. A graphic description of the RUG III classification system is set forth in appendix D to this rule.

(F) The RUG III classification system has forty-four different groups. All MDS 3.0 data elements related to the RUG III classification system must be completed before a resident can be classified. Residents whose MDS 3.0 forms contain missing or out-of-range responses to data elements used to determine the RUG III classification shall be assigned by default into a forty-fifth group. Corrections to MDS 3.0 data can be made only as described in paragraph (D) of rule 5101:3-3-43.1 of the Administrative Code.

(G) The relationship between resident characteristics and resource utilization, as measured by staff time for the registered nurses (RNs), licensed practical nurses (LPNs), and nurse aides (NAs) worker classifications, was analyzed for the RUG III system to identify characteristics which differentiate resource use among residents. Staff time and assessment data were collected by the federal multistate nursing home case-mix and quality demonstration project for the purpose of establishing common nursing staff times associated with all resident categories that are standard across residents, nursing staff, facilities, units and states. Resident specific and resident non-specific time for each worker classification (RN, LPN, and NA) was averaged for each of the forty-four RUG III groups.

(H) Each of the forty-four RUG III groups is assigned a relative resource weight. This weight indicates the relative amount of staff time required on average for all three worker classifications listed in paragraph (G) of this rule to deliver care to residents in that RUG III group.

(1) The relative resource weight is calculated as follows using the average minutes per worker classification per RUG III group provided by the United States department of health and human services, and three-year averages, beginning with calendar year 1989, of RN, LPN, and NA wages in Ohio medicaid certified NFs as reported to ODJFS.

(a) By setting the NA wage weight at one, wage weights for RNs and LPNs are calculated by dividing the NA wage into the RN or LPN wage.

(b) To calculate the total weighted minutes for each RUG III group, the wage weight for each worker classification is multiplied by the average number of minutes that classification of workers spends caring for a resident in the RUG III group and the products are summed.

(c) The RUG III group with the lowest total weighted minutes receives a relative resource weight of one. Relative resource weights are calculated by dividing the lowest group's total weighted minutes into each group's total weighted minutes. Weight calculations are rounded to the fourth decimal place.

(2) The lowest weight for the forty-four RUG III groups is used as the weight for the forty-fifth default group.

(3) Relative resource weights for the forty-five NF case-mix RUG III groups are set forth in appendix E to this rule.

(4) Except as provided in paragraph (H)(4)(b) of this rule, relative resource weights may be recalibrated using wage weights based on three-year statewide averages of RN, LPN, and NA wages in Ohio NFs as reported on the long term care facility medicaid cost report for NFs, and minutes per worker classification per RUG III group as follows:

(a) Upon receipt of revised worker classification minutes from the United States department of health and human services, ODJFS shall recalibrate the relative resource weights based on the revised minutes and the averages of RN, LPN, and NA wages from cost report data from the most recent three calendar years, to be effective at the beginning of the next state fiscal year.

(b) ODJFS may recalibrate the relative resource weights at least once every ten years, using the most current worker classification minutes from the United States department of health and human services and the average worker classification wages, to be effective at the beginning of the next state fiscal year. When recalibrating the relative resource weights, as permitted by paragraph (H)(4)(b) of this rule ODJFS shall use cost report wage data from the most recent three calendar years available ninety days prior to the start of the fiscal year.

(c) ODJFS may recalibrate relative resource weights more frequently if significant variances in wage ratios between worker classifications occur.

(d) After recalibrating relative resource weights under paragraph (H)(4)(a), (H)(4)(b), or (H)(4)(c) of this rule, ODJFS shall use the recalibrated relative resource weights to calculate the semiannual NF case mix score effective for the start of the fiscal year and to recalculate the annual NF case mix score for the calendar year preceding the fiscal year.

Replaces: 5101:3-3- 43.2

Click to view Appendix

Click to view Appendix

Click to view Appendix

Click to view Appendix

Click to view Appendix

Click to view Appendix

Click to view Appendix

Click to view Appendix

Click to view Appendix

Click to view Appendix

Effective: 10/01/2010
R.C. 119.032 review dates: 10/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.232
Prior Effective Dates: 4/15/93 (Emer.), 7/1/93, 9/30/93 (Emer.), 1/1/94, 7/1/96 (Emer.), 9/1/96, 7/1/98, 7/1/99 (Emer.), 8/12/99, 7/1/02, 7/1/05, 2/2/06, 7/1/06

5160-3-43.3 Calculation of quarterly, semiannual and annual nursing facility (NF) average case mix scores.

(A) The definitions of all terms used in this rule are the same as set forth in rules 5101:3-3-01, 5101:3-3-43.1 and 5101:3-3- 43.4 of the Administrative Code.

(B) The Ohio department of job and family services (ODJFS) shall process resident assessment data submitted by NFs in accordance with rule 5101:3-3-43.1 of the Administrative Code and shall classify residents using the resource utilization groups, version III (RUG III) classification system to determine resident case mix scores in accordance with rule 5101:3-3-43.2 of the Administrative Code. These resident case mix scores, based on relative resource weights as set forth in appendix E of rule 5101:3-3-43.2 of the Administrative Code, are used to establish two quarterly facility average case mix scores each quarter.

(1) The first quarterly facility average case mix score shall be calculated using all records selected for the quarter and shall be the quarterly facility average total case mix score.

(2) The second quarterly facility average case mix score shall be calculated using only the records selected for the quarter that ODJFS identifies as medicaid records and shall be the quarterly facility average medicaid case mix score.

(C) ODJFS shall calculate a quarterly facility average total case mix score for all providers meeting the following requirements:

(1) In accordance with rule 5101:3-3-43.1 of the Administrative Code, the provider submitted resident assessment information by the filing date, and the data included resident assessments for all residents in medicaid certified beds as of the reporting period end date, and

(a) The provider's resident assessment data submitted timely for that reporting quarter provided sufficient information for accurately classifying at least ninety per cent of all residents in medicaid certified beds into RUG III groups one through forty-four, or

(b) The provider's resident assessment data submitted timely and corrected timely, in accordance with the procedures outlined in rule 5101:3-3-43.1 of the Administrative Code for correcting incomplete or inaccurate information, for that reporting quarter, provided sufficient information for accurately classifying at least ninety per cent of all residents in medicaid certified beds into RUG III groups one through forty-four; and

(c) There were no errors as described in paragraph (D) of rule 5101:3-3-43.1 of the Administrative Code that prevented ODJFS from verifying the records to be used in determining the quarterly facility average total case mix score.

(d) The prospective payment system (PPS) other medicare required assessments (OMRAs) may not be selected for calculating case mix scores due to the inability to assign the record to a RUG III classification.

(2) The quarterly facility average total case mix score for providers that submitted their minimum data set version 3.0 (MDS 3.0) data in compliance with paragraph (C)(1) of this rule shall be calculated as follows:

(a) All resident case mix scores for the quarter, including resident case mix scores in the forty-fifth RUG III group, are added together; then

(b) The sum of resident case mix scores is divided by the total number of residents.

(3) If a provider does not comply with paragraph (C)(1) of this rule, ODJFS shall assign the NF a penalty score. The penalty score for the quarterly facility average total case mix score shall be a score that is five per cent less than the quarterly facility average total case mix score for the preceding calendar quarter.

(a) If the facility was subject to an exception review, in accordance with rule 5101:3-3-43.4 of the Administrative Code, for the preceding quarter, the assigned quarterly total facility average case mix score shall be the score that is five per cent less than the score determined by the exception review.

(b) If the facility was assigned a quarterly facility average total case mix score for the preceding calendar quarter, the assigned quarterly facility average total case mix score shall be the score that is five per cent less than the score assigned for the preceding quarter.

(D) ODJFS shall calculate a quarterly facility average medicaid case mix score for all providers meeting the following requirements:

(1) The provider's resident assessment data submitted timely for that reporting quarter provide sufficient information for classifying at least ninety per cent of records identified as medicaid records into RUG III groups one through forty-four, or

(a) The provider's resident assessment data submitted timely and corrected timely, in accordance with the procedure outlined in rule 5101:3-3-43.1 of the Administrative Code for correcting incomplete or inaccurate information, for that reporting quarter, provided sufficient information for accurately classifying at least ninety per cent of all residents into RUG III groups one through forty-four; and

(b) There were no errors as described in paragraph (D) of rule 5101:3-3-43.1 of the Administrative Code that prevented ODJFS from verifying the records to be used in determining the quarterly facility average medicaid case mix score.

(2) ODJFS shall identify a MDS 3.0 as a medicaid record if the MDS 3.0 meets the following requirements:

(a) The MDS 3.0 is not completed to meet the requirements for a medicare part A stay.

(b) The social security number (SSN) on the MDS 3.0 matches a SSN on the medicaid recipient master file (RMF) and

(c) The assessment reference date (ARD) on the MDS 3.0 falls within the recipient's medicaid eligibility span.

(3) The quarterly facility average medicaid case mix score for providers that submitted their MDS 3.0 data in compliance with paragraph (C)(1) of this rule shall be calculated as follows:

(a) Medicaid resident case mix scores for the quarter, including resident case mix scores in the forty-fifth RUG III group, are added together; then

(b) The sum of medicaid resident case mix scores is divided by the total number of medicaid residents.

(4) If a provider does not comply with paragraph (D)(1) of this rule, ODJFS may assign the NF a penalty score. The penalty score for the quarterly facility average medicaid case mix score may be a score that is five per cent less than the quarterly facility average medicaid case mix score for the preceding calendar quarter.

(a) If the facility was subject to an exception review, in accordance with rule 5101:3-3-43.4 of the Administrative Code, for the preceding quarter, the assigned quarterly facility average medicaid case mix score may be the score that is five per cent less than the score determined by the exception review.

(b) If the facility was assigned a quarterly facility average medicaid case mix score for the preceding calendar quarter, the assigned quarterly facility average medicaid case mix score may be the score that is five per cent less than the score assigned for the preceding quarter.

(5) ODJFS shall use a facility's assigned penalty score to calculate the semiannual facility average medicaid case mix score.

(E) This paragraph describes the method for calculating the semiannual facility average medicaid case mix score.

(1) The semiannual facility average medicaid case mix score for the payment period beginning the first day of July for a given fiscal year shall be the average of the quarterly facility average medicaid case mix score from the preceding December and March reporting quarters. If a facility does not have a quarterly facility average medicaid case mix score for both the December and March reporting quarters, the median annual average case mix score for the NF's peer group shall be assigned as the semiannual facility average medicaid case mix score to determine the direct care rate.

(2) The semiannual facility average medicaid case mix score for the payment period beginning the first day of January for a given fiscal year shall be the average of the quarterly facility average medicaid case mix score from the preceding June and September reporting quarters. If a facility does not have a quarterly facility average medicaid case mix score for both the June and September reporting quarters, the median annual average case mix score for the NF's peer group shall be assigned as the semiannual facility average medicaid case mix score to determine the direct care rate.

(F) ODJFS shall calculate the annual facility average case mix score as follows:

(1) The annual facility average case mix score shall be calculated only for facilities with at least two quarterly facility average total case mix scores meeting the requirements of paragraphs (C)(1) and (C)(2) of this rule. In addition for any score meeting the requirements of paragraphs (C)(1) and (C)(2) that was adjusted, the adjusted score will be substituted according to the following hierarchy:

(a) Adjusted quarterly facility average total case mix scores established by a rate reconsideration decision resulting from an exception review of resident assessment information conducted before the effective date of the rate; or

(b) Adjusted quarterly facility average total case mix scores as a result of exception review findings.

(2) If ODJFS assigned a facility a quarterly facility average total case mix score in accordance with paragraph (C)(3) of this rule, said assigned score will not be used to calculate the provider's annual facility average case mix score.

(3) The qualifying case mix scores shall be summed and divided by the total number of quarters of qualifying scores to arrive at the annual facility average case mix score.

(G) For each provider that submits MDS 3.0 data in a given week, ODJFS shall send the "Case Mix Report" containing the following four components:

(1) The "Provider Detail Listing of Successfully Grouped Records," identifies records that were successfully grouped by ODJFS. The report will include all records received, even if the records will not be used in the quarterly score calculation;

(2) The "Critical Error Summary," that identifies the provider's records that will be assigned into the default group forty-five unless they are corrected before the end of the reporting quarter in accordance with rule 5101:3-3-43.1 of the Administrative Code.

(3) The "Provider Detail Listing of Records with Critical Errors," provides detail for each record listed on the "Critical Error Summary" identifying the failed edits.

(4) The "Discharge and Reentry Tracking Form Summary," that identifies all discharge assessments and reentry tracking forms that were received by ODJFS.

(H) ODJFS shall provide two preliminary "Calculation of Facility Case Mix Scores" reports. The first report will reflect records submitted up to the quarterly filing date. The second report will reflect records submitted up to approximately two weeks prior to the quarterly corrections deadline. Both reports will include a calculation of the quarterly facility average total case mix score and the quarterly facility average medicaid case mix score. Providers may file corrections to the extent permitted by rule 5101:3-3-43.1 of the Administrative Code.

(I) After the quarterly corrections deadline specified in rule 5101:3-3-43.1 of the Administrative Code, ODJFS shall provide a final "Calculation of Facility Case Mix Scores" report. The report will include a calculation of the quarterly facility average total case mix score and the quarterly facility average medicaid case mix score.

(J) Following the determination of the two quarterly facility average medicaid case mix scores used to calculate the semiannual medicaid case mix scores effective July first and January first of the fiscal year, ODJFS shall provide a "Semiannual Medicaid Case Mix Score Calculation Report" to each provider.

(K) Following the calculation of the annual facility average case mix score, ODJFS shall provide an "Annual Facility Average Case Mix Score Calculation Report" to each provider.

Effective: 10/01/2010
R.C. 119.032 review dates: 07/14/2010 and 10/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.231 , 5111.232
Prior Effective Dates: 4/15/93 (Emer.), 7/1/93, 7/1/94 (Emer.), 9/30/94, 4/20/95, 7/1/98, 1/1/03, 7/1/05, 2/13/06, 7/1/06

5160-3-43.4 Exception review process for nursing facilities (NFs).

(A) The definitions of all terms not defined in this rule are the same as set forth in rules 5101:3-3-01 and 5101:3-3-43.1 of the Administrative Code.

(1) "Combination review" is a type of exception review where the Ohio department of job and family services (ODJFS) reviews records selected in one of the following ways:

(a) A combination of records selected pursuant to random and targeted criteria; or

(b) Records initially selected for a targeted review, but insufficient records were available to meet the targeted review sample size requirements, are combined with randomly selected records to complete the sample size.

(c) Records initially selected for a random review combined with records selected for a targeted review as a result of findings of the random review.

(2) "Exception review" is a review of minimum data set (MDS) assessment data. It is conducted at a selected nursing facility (NF) by registered nurses and other appropriate licensed or certified health professionals employed by or under contract with ODJFS for purposes of identifying any patterns or trends related to resident assessments submitted in accordance with rule 5101:3-3-43.1 of the Administrative Code, which could result in inaccurate case mix scores used to calculate the direct care rate.

(3) "Effective date of the rate" is either the first day of July or January for a given fiscal year.

(4) "Exception review tolerance level" is the level of variance between the facility and ODJFS in MDS assessment item responses affecting the resource utilization groups, version III (RUG III) classification of a facility's residents. Two kinds of tolerance levels have been established for exception reviews: initial sample tolerance level, and expanded review tolerance level.

(a) "Initial sample tolerance level" is the percentage of unverifiable records found during the initial sample of an exception review, below which no further review will be pursued for the same six month period. The initial sample tolerance level shall be less than fifteen per cent of the entire sample.

(b) "Expanded review tolerance level" is an acceptable level of variance in the calculation of a provider's quarterly facility average medicaid case mix score or an acceptable per cent of the records sampled at exception review that were unverifiable.

(5) "Random review" is a type of exception review that examines randomly selected records from any of the RUG III major categories identified in rule 5101:3-3-43.2 of the Administrative Code.

(6) "Record" is an MDS assessment identified as a medicaid record as set forth in paragraph (D)(2) of rule 5101:3-3-43.3 of the Administrative Code.

(7) "Targeted review" is a type of exception review that targets records in restorative nursing programs, current toileting program or trial, and/or bowel toileting program, clinically complex with symptoms of depression, or one or more of the seven mutually exclusive RUG III major categories identified in rule 5101:3-3-43.2 of the Administrative Code. Nursing rehabilitation/restorative care includes records grouped in the following RUG III classifications: RLB, RLA, IB2, IA2, BB2, BA2, PE2, PD2, PC2, PB2, and PA2 as identified in rule 5101:3-3-43.2 of the Administrative Code. Clinically complex with depression includes records grouped in the following RUG III classification: CC2, CB2, and CA2 as identified in rule 5101:3-3-43.2 of the Administrative Code.

(8) The "variance" is the percentage difference between the quarterly facility average medicaid case mix score based on exception review findings and the quarterly facility average medicaid case mix score from the provider's submitted MDS records.

(a) The exception review tolerance level shall be either less than a two per cent variance between the quarterly facility average medicaid case mix score based on exception review findings and the quarterly facility average medicaid case mix score from the provider's submitted MDS records or less than twenty per cent of the medicaid records sampled at exception review were unverifiable.

(b) The variance calculation will not recognize modifications to MDS

assessments and new assessments following an inactivation, submitted by the facility after notification of the exception review.

(9) A "verifiable MDS record" is a provider's completed MDS assessment form, based on facility supplied MDS assessment data, submitted to the state for a resident for a specific reporting quarter, which upon examination by ODJFS during an exception review, has been determined to accurately represent the aspects of the resident's condition, during the specified assessment time frame, that affect the correct RUG III classification of that record.

(10) An "unverifiable MDS record" is a provider's completed MDS assessment form, based on facility supplied MDS assessment data, submitted to the state for a resident for a specific reporting quarter which, upon examination by ODJFS, has been determined to inaccurately represent the aspects of the resident's condition, during the specified assessment time frame, that affect the RUG III classification of that record. MDS coding may be deemed unsupported if inconsistencies are found in the sources of information through verification activities.

(B) All exception reviews will comply with the applicable provisions of the medicare and medicaid programs.

(C) Providers may be selected for an exception review by ODJFS based on any of the following:

(1) The findings of a certification survey conducted by the Ohio department of health that may indicate that the facility is not accurately assessing residents, which may result in the resident's inaccurate classification into the RUG III system;

(2) A risk analysis profile that may include, but is not limited to, one or more of the following:

(a) A change in the frequency distribution of their residents in the major RUG III categories, nursing rehabilitation/restorative care, or clinically complex with depression; or

(b) The frequency distribution of residents in the major RUG III categories, nursing rehabilitation/restorative care, or clinically complex with depression that exceeds statewide averages; or

(c) A sudden or drastic change in the facility average case mix score; or

(d) A change in the frequency distribution of coded responses to a MDS item.

(3) Prior resident assessment performance of the provider, may include but is not limited to, ongoing problems with assessment submission deadlines, error rates, incorrect assessment dates, and apparent unchanged assessment practice(s) following a previous exception review.

(D) Exception reviews shall be conducted at the facility by registered nurses and other licensed or certified health professionals under contract with or employed by ODJFS. When a team of ODJFS reviewers conducts an on-site exception review, the team shall be led by a registered nurse. Persons conducting exception reviews on behalf of ODJFS shall meet the following conditions:

(1) During the period of their professional employment with ODJFS, reviewers must neither have nor be committed to acquire any direct or indirect financial interest in the ownership, financing, or operation of a NF which they review in Ohio.

(2) Reviewers shall not review any provider where a member of their family is a current resident.

(3) Reviewers shall not review any provider that has been a client of the reviewer within the past twenty-four months.

(4) Employment of a member of a health professional's family by a provider that the professional does not review does not constitute a direct or indirect financial interest in the ownership, financing, or operation of a NF.

(5) Reviewers shall not review any provider that has been an employer of the reviewer within the past twenty-four months.

(E) Prior notice: ODJFS shall notify the provider by telephone at least two working days prior to the review.

(F) Providers selected for exception reviews must provide ODJFS reviewers with reasonable access to residents, professional and nonlicensed direct care staff, the facility assessors, and completed resident assessment instruments and supporting documentation regarding the residents' care needs and treatments. Providers must also provide ODJFS with sufficient information to be able to contact the resident's attending or consulting physicians, other professionals from all disciplines who have observed, evaluated or treated the resident, such as contracted therapists, and the resident's family/significant others. These sources of information may help to validate information provided on the resident assessment instrument submitted to the state. Verification activities may include reviewing resident assessment forms and supporting documentation, conducting interviews with staff knowledgeable about the resident during the observation period for the MDS , and observing residents.

(G) An exception review shall be conducted of a random, targeted, or a combination of random and targeted samples of completed resident assessment instruments. The initial sample size shall be greater than or equal to the minimum sample size presented in appendix A to this rule. The expanded sample is based on the initial sample findings. The expanded sample size is presented in appendix B to this rule.

(H) Results from review of the initial sample shall be used to decide if further action by ODJFS is warranted. If the initial sample is to be expanded for further review, ODJFS reviewers shall hold a conference with facility representatives advising them of the next steps of the review and discussing the initial sample findings. If the sample of reviewed records exceeds the initial sample tolerance level described in paragraph (A)(4)(a) of this rule, ODJFS:

(1) May subsequently expand the exception review process to review MDS assessments as follows:

(a) If the initial sample was a targeted review, the expanded sample size shall be the lesser of the remaining records in the targeted category or the applicable minimum expanded sample size presented in appendix B to this rule.

(b) If the initial sample was a random review that became a targeted review, the expanded sample shall be the lesser of the remaining records in the targeted category or the applicable minimum expanded sample size presented in appendix B to this rule.

(c) If the initial sample was a random review, the expanded sample size shall be at least the applicable minimum sample size as presented in appendix B to this rule.

(d) If the initial sample was a combination review, the expanded sample size shall be at least the applicable minimum sample size as presented in appendix B to this rule. The expanded sample may consist of the remaining records in the targeted and random categories.

(e) If the expanded review tolerance level is exceeded, ODJFS may subsequently expand the sample size for the same reporting quarter up to and including one hundred per cent of the records and continue the review process.

(I) At the conclusion of the on-site portion of the exception review process, ODJFS reviewers shall hold an exit conference with facility representatives. Reviewers will share preliminary findings and/or concerns about verification or failure to verify RUG III classification for reviewed records. Reviewers will give provider representatives one written preliminary copy of the exception review findings indicating whether the facility was under or over the established tolerance levels.

(J) All exception reviews shall include a final written summary of the exception review findings including the final facility tolerance level calculations and revised quarterly facility average total case mix score and revised quarterly facility average medicaid case mix score. ODJFS shall mail a copy of the final written summary to the provider.

(K) All exception review reports shall be retained by ODJFS for at least six years.

(L) If the expanded review tolerance level is exceeded, ODJFS shall use the exception review findings to calculate or recalculate resident case mix scores, quarterly, semiannual, and annual facility average case mix scores. Calculations or recalculations shall apply only to records actually reviewed by ODJFS and shall not be based on extrapolations to unreviewed records of findings from reviewed records. For example, ODJFS shall recalculate quarterly facility average case mix scores by replacing resident case mix scores of reviewed records and not changing the resident case mix scores of unreviewed records.

(M) ODJFS shall use the quarterly, semiannual, and annual facility average case mix scores based on exception review findings which exceed the exception review tolerance level to calculate or recalculate the facility's rate for direct care costs for the appropriate six month period(s). However, scores recalculated based on exception review findings shall not be used to override any assignment of a quarterly facility average case mix score or a peer group cost per case mix unit made in accordance with rule 5101:3-3-43.3 of the Administrative Code as a result of the facility's failure to submit, or submission of incomplete or inaccurate resident assessment information, unless the recalculation results in a lower quarterly or semiannual facility average case mix score or peer group cost per case mix unit than the one to be assigned.

(1) If the exception review of a specific reporting quarter is conducted before the effective date of the rate for the corresponding six month period, and the review results in findings that exceed the tolerance level, ODJFS shall use the recalculated quarterly facility average case mix scores to calculate the facility's semiannual average case mix score for the facility's direct care rate for that six month period. Calculated rates based on exception review findings may result in a rate increase or rate decrease compared to the rate based on the facility's submission of assessment information.

(2) If the exception review of a specific reporting quarter is conducted after the effective date of the rate for a corresponding six month period, and the review results in findings that exceed the exception review tolerance level and indicate the facility received a lower rate than it was entitled to receive, ODJFS shall increase the direct care rate prospectively for the remainder of the six month period, beginning one month after the first day of the month after the exception review is completed.

(3) If the exception review of a specific reporting quarter is conducted after the effective date of the rate for a corresponding six month period, and the review results in findings that exceed the exception review tolerance level and indicate the facility received a higher rate than it was entitled to receive, ODJFS shall reduce the direct care rate and apply it to the six month periods when the provider received the incorrect rate to determine the amount of the overpayment. Overpayments are payable in accordance with rule 5101:3-3-22 of the Administrative Code.

(N) Except for additional information submitted to ODJFS as part of the processes set forth in paragraphs (O) and (P) of this rule, the ODJFS exception review determination for any resident case mix score shall be considered final. A provider may submit corrections for individual records in accordance with rule 5101:3-3-43.1 of the Administrative Code; however, the exception review determination for any resident assessment case mix score will be used to establish the facility average case mix score.

(O) The provider may seek reconsideration of any prospective direct care rate which was established by recalculating the direct care rate as a result of an exception review of resident assessment information conducted before the effective date of the rate. Requests for rate reconsideration related to exception review findings must be submitted in accordance with the following procedures:

(1) A reconsideration of a prospective direct care rate on the basis of a dispute with ODJFS exception review findings shall be submitted to ODJFS no more than thirty days after receipt of exception review findings.

(2) The request for a reconsideration of a prospective rate on the basis of a dispute with exception review findings shall be filed in accordance with the following procedures:

(a) The request shall be in writing; and

(b) The request shall be addressed to "Ohio Department of Job and Family Services, Ohio Health Plans, Bureau of Long Term Care Services and Supports, Disability and Aging Policy Section"; and

(c) The request shall indicate that it is a request for rate reconsideration due to a dispute with exception review findings; and

(d) The request shall include a detailed explanation of the items on the resident assessment records under dispute as well as copies of relevant, supporting documentation from specific individual records. The request shall also include the provider's proposed resolution.

(3) ODJFS shall respond in writing within sixty days of receiving each written request for a rate reconsideration related to disputed exception review findings. If ODJFS requests additional information to determine if the rate adjustment is warranted, the provider shall respond in writing and shall provide additional supporting documentation no more than thirty days after the receipt of the request for additional information. ODJFS shall respond in writing within sixty days of receiving the additional information to the request for a rate reconsideration due to disputed exception review findings.

(4) If the rate is increased pursuant to a rate reconsideration due to disputed exception review findings, the rate adjustment shall be implemented retroactively to the initial service date for which the rate is effective.

(5) When calculating the annual and semiannual facility average case mix scores in accordance with rule 5101:3-3-43.3 of the Administrative Code, ODJFS shall use any resident case mix scores adjusted as a result of a rate reconsideration determination in lieu of the resident case mix scores from the exception review findings.

(P) The findings of an exception review conducted after the effective date of the rate may be appealed under provisions of the Administrative Procedure Act, Chapter 119. of the Revised Code. ODJFS shall not withhold from the facility's current payments any amounts ODJFS claims to be due from the facility as a result of the exception review findings while the provider is pursuing administrative or judicial remedies in good faith.

Click to view Appendix

Click to view Appendix

Effective: 10/01/2010
R.C. 119.032 review dates: 07/14/2010 and 10/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.27
Prior Effective Dates: 10/1/94, 7/1/98, 7/1/02, 2/2/06, 7/1/06, 4/1/07

5160-3-57 Nursing facilities (NFs): tax cost add-on.

(A) The Ohio department of medicaid (ODM) shall pay a provider a per resident per day rate for tax costs determined under section 5165.21 of the Revised Code.

(B) If a provider does not have a cost report filed with ODM for the applicable calendar year used to determine the rate for tax costs under section 5165.21 of the Revised Code, the NF provider shall be paid a rate for tax costs that is the median rate for tax costs for the facility's peer group determined in division (C) of section 5165.16 of the Revised Code.

Effective: 10/03/2014
Five Year Review (FYR) Dates: 07/01/2014 and 10/03/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5165.21
Prior Effective Dates: 7/1/06

5160-3-58 [Rescinded] Quality incentive payment for nursing facilities (NFs).

Effective: 08/15/2014
R.C. 119.032 review dates: 05/19/2014
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5165.10 , 5165.25
Prior Effective Dates: 6/30/06 (Emer.), 9/28/06, 3/19/12

5160-3-64 Nursing facility payment for medicare part A cost sharing.

(A) For nursing facility services the nursing facility provides on or after January 1, 2012, "medicaid maximum allowable amount" means one hundred per cent of the nursing facility's medicaid rate on the date that the service was provided.

(B) For qualified medicare beneficiaries (QMB) including QMB plus as defined in rule 5101:3-1-05.2 of the Administrative Code and medicaid consumers admitted to a nursing facility as a medicare part A benefit, the Ohio department of job and family services (ODJFS) will pay as cost sharing for nursing facility services the lesser of:

(1) The coinsurance amount as provided by the medicare part A plan; or

(2) The medicaid maximum allowable amount for the identified service or services minus the medicare part A plan's payment to a nursing facility for the same service or services. If the medicare part A plan's payment to a nursing facility for a service or services identified is greater than the medicaid maximum allowable amount, ODJFS will pay nothing for the same identified service or services.

(C) The medicaid provider is ultimately responsible for accurate and valid reporting of medicaid claims submitted for payment. Providers submitting medicare part A crossover claims to the medicaid program must be able to provide upon request documentation that supports that the information provided on the claim matches the information on the part A plan's remittance advice.

Effective: 03/19/2012
R.C. 119.032 review dates: 12/15/2011 and 03/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.225
Prior Effective Dates: 7/1/05

5160-3-64.1 Nursing facilities (NFs): payment for cost-sharing other than medicare part A.

(A) For medicaid eligible NF residents, the NF per diem rate includes medicaid payments for medicare or other third-party insurance cost-sharing, including coinsurance or deductible payments, associated with services that are included in the NF per diem.

(B) Neither the medicaid eligible NF resident nor the Ohio department of medicaid (ODM) is responsible for any medicare or other third-party insurance cost-sharing, including coinsurance or deductibles, associated with services that are included in the NF per diem.

Effective: 10/03/2014
Five Year Review (FYR) Dates: 07/01/2014 and 10/03/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5165.47
Prior Effective Dates: 7/31/09 (Emer.), 10/29/09

5160-3-65 Nursing facilities (NFs): rates for providers with an initial date of certification on or after July 1, 2006.

(A) The Ohio department of job and family services (ODJFS) shall determine the initial rate for the fiscal year in which the NF begins participation in the medicaid program for a NF with a first date of licensure and subsequent certification on or after July 1, 2006, including a NF that replaces one or more existing facilities, or a NF with a first date of licensure before that date that was initially certified for the medicaid program on or after that date under section 5111.254 of the Revised Code.

(1) If the number of beds in the replacement facility is greater than the number of beds in the replaced facility, the case mix score shall be equal to the weighted average of the semiannual case mix score used for the replaced beds on the last day of service at the replaced facility and the median annual average case mix score for the NF's peer group for the additional beds.

(2) If a rate for direct care costs is determined under section 5111.254 of the Revised Code for a NF using the median annual average case mix score for the NF's peer group, the rate shall be redetermined to reflect the NF's actual semiannual case mix score determined under section 5111.232 of the Revised Code after the NF submits its first two quarterly assessment data that qualify for use under paragraph (E) of rule 5101:3-3-43.3 of the Administrative Code. If the NF's quarterly submissions do not qualify for use in calculating a case mix score, ODJFS shall continue to use the median annual average case mix score for the NF's peer group in lieu of the NF's semiannual case mix score until the NF submits two consecutive quarterly assessment data that qualify for use in calculating a case mix score.

(B) After the end of the fiscal year in which the NF began participation in the medicaid program, the rates for the second fiscal year and subsequent fiscal years shall be set in accordance with division (A) of section 5111.222 of the Revised Code.

Effective: 07/01/2006
R.C. 119.032 review dates: 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.254

5160-3-65.1 Nursing facilities (NFs): rates for providers that change provider agreements.

(A) For an entering NF operator, as defined under section 5111.65 of the Revised Code, that begins participation in the medicaid program with an initial date of July 1, 2006 through October 31, 2006, the Ohio department of job and family services (ODJFS) shall determine the initial rate as the lesser of the following:

(1) The rate the exiting operator would have received on the date the entering operator begins participation in the medicaid program; or

(2) The sum of the following:

(a) The rate for direct care costs shall be the product of the cost per case mix unit determined under division (D) of section 5111.231 of the Revised Code for the facility's peer group and the case mix score that would have been used for the exiting operator on the day that the entering operator begins participation in the medicaid program.

(b) The rate for ancillary and support costs shall be the median rate for the facility's peer group determined under division (D) of section 5111.24 of the Revised Code.

(c) The rate for capital costs shall be the median rate for the facility's peer group determined under division (D) of section 5111.25 of the Revised Code.

(d) The rate for tax costs as defined in section 5111.242 of the Revised Code shall be the median rate for tax costs for the facility's peer group in which the facility is placed under division (C) of section 5111.24 of the Revised Code.

(e) The quality incentive payment shall be the mean payment specified under rule 5101:3-3-58 of the Administrative Code.

(f) The rate for franchise permit fees determined for the NF under section 5111.243 of the Revised Code.

(B) On November 1, 2006, a NF operator that began participation in the medicaid program through a change of provider agreement July 1, 2006 through October 31, 2006, shall receive the rate the exiting operator would have received had the exiting operator continued to participate in the medicaid program.

(C) For an entering NF operator that begins participation in the medicaid program on and after November 1, 2006, the NF operator's initial rate shall be the rate the exiting operator would have received had the exiting operator continued to participate in the medicaid program.

(D) The rate determined in paragraphs (A), (B) and (C) of this rule shall not be subject to adjustment until the following fiscal year.

(E) After the end of the fiscal year in which the NF began participation in the medicaid program, the rates for the second fiscal year and subsequent fiscal years shall be set in accordance with sections 5111.20 to 5111.33 of the Revised Code. The rate for direct care costs shall be redetermined to reflect the entering operator's actual semiannual case mix score determined under section 5111.232 of the Revised Code after the NF submits its first two quarterly assessment data that qualify for use under paragraph (E) of rule 5101:3-3-43.3 of the Administrative Code.

Effective: 11/01/2006
R.C. 119.032 review dates: 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.676
Rule Amplifies: 5111.222 , 5111.254 , 5111.676
Prior Effective Dates: 7/1/2006

5160-3-99 Payment methodology for state-operated intermediate care facilities for the mentally retarded (ICFs-MR).

This rule describes the methodology for calculating payment rates for state-operated intermediate care facilities for the mentally retarded (ICFs-MR) and includes provisions for a temporary additional payment for off-site day habilitation/active treatment and associated transportation services.

(A) Definitions.

(1) "State-operated intermediate care facility for the mentally retarded" also referred to as "facility" means an intermediate care facility for the mentally retarded as described in paragraph (N) of rule 5101:3-3-01 of the Administrative Code that is operated under a medicaid provider agreement(s) by the Ohio department of mental retardation and developmental disabilities(ODMRDD).

(2) "Cost report" means form number JFS 01984, "Developmental Center Cost Report" (2/2004) used to report cost and statistical data for the operation of a state-owned ICF-MR. The cost report includes all worksheets as included in appendix A to this rule and covers the period of July first to June thirtieth.

(3) "Direct care costs" means those costs established by summing the amounts on the cost report worksheet B P1, column 16a, line 16 and worksheet C P1, column 16a, line 16 minus worksheet B P2, column 16a, line 16 and minus worksheet C P2, column 16a, line 16.

(4) "Ancillary costs" means those costs established by the amounts on the cost report worksheet B P1, column 16a, lines 17 to 21 and worksheet B P2, column 16a, lines 17 through 21. Ancillary costs include pharmacy, radiology, laboratory, clinic and physician services. Audiology, dental and vision costs are included in clinic services.

(5) "Capital costs" means those costs established by summing the amounts on the cost report worksheet B P2, column 16a, line 16 and worksheet C P2, column 16a, line 16.

(6) "Total inpatient days" means the sum of inpatient days and leave days as reported on worksheet F of the cost report.

(7) "Covered services" means ICF-MR covered services.

(8) "Base year" means the period used to establish the interim payment rate for each state-operated ICF-MR.

(9) "Rate year" means the period where calculated interim rates are paid using base year cost report data.

(10) "Base year cost report" means form JFS 01984, "Developmental Center Cost Report" (2/2004) used to report costs and statistical data as filed during a twelve-month period to determine the interim payment rate for each state-operated ICF-MR.

(11) "Rate year cost report" means form JFS 01984 used to report costs and statistical data during a twelve-month period to determine the final payment rate for each state-operated ICF-MR.

(12) "Interim payment rate" means the rate of payment calculated using the desk reviewed base year cost report data.

(13) "Final payment rate" means the rate of payment calculated using the final rate year cost report data.

(14) "Reasonable and allowable costs" means cost items prepared in accordance with medicare principles governing reasonable and allowable cost reimbursement set forth in the providers' reimbursement manual "CMS Publications 15-1 and 15-2" with the exception of the restrictions related to dental services, available at www.cms.hhs.gov/Manuals/PBM/list.asp#TopOfPage in effect as of September 8, 2005.

(15) "Adjusted interim payment rate" means the interim payment rate plus the amount calculated in paragraphs (C)(4) and (C)(5) of this rule applicable for state fiscal year 2006 and 2007 only.

(B) Source data for calculations.

(1) The calculations described in this rule will be based on the most recent desk reviewed base year cost report data submitted to the department in accordance with division 5101:3 of the Administrative Code. The state-operated ICF-MR cost report must:

(a) Be prepared in accordance with medicare principles governing reasonable and allowable cost reimbursement set forth in the providers' reimbursement manual "CMS Publications 15-1 and 15-2"with the exception of the restrictions related to dental services, available at www.cms.hhs.gov/Manuals/PBM/list.asp#TopOfPage in effect as of September 8, 2005 and 45 CFR part 92. The method used to allocate supporting cost centers shall be the step-down method described in centers for medicare and medicaid services (CMS) publication 15, section 2306.1. The statistics, on the approved cost reporting form, must be used for cost allocation purposes unless alternative statistics which yield a more accurate and/or appropriate allocation of costs are approved by the department. A written request to use alternative statistics must be submitted to and approved by the department prior to the period in which the statistics are to be used; and

(b) Include all information necessary for the proper determination of costs payable under medicaid including financial records and statistical data; and

(c) Include the cost report certification executed ODMRDD fiscal attesting to the accuracy of the cost report; and in addition, all subsequent revisions to the cost report must include an executed certification; and

(d) Include costs for all covered services generally available to medicaid recipients and provided to recipients by the state-operated ICFs-MR, either directly or by arrangement, shall be included in the costs reported by the state-operated ICFs-MR on the form approved by ODJFS and shall be reimbursed only to the state-operated ICFs-MR. These costs are subject to all otherwise applicable audit guidelines and tests of reasonableness; and

(e) Not include the cost of pharmacy and legend drugs in their cost reports when these are reimbursed directly to a pharmacy provider.

(2) A desk review will be performed by the ODJFS on all annual cost reports for the purpose of updating interim payment rates, all of which are subject to cost settlement. Desk review procedures will take into consideration the relationship between the prior year's audited costs and the current year's reported costs. Adjustments may be made to the cost report by the department as necessary to determine reasonable and accurate interim payment rates. Adjustments made by ODJFS do not preclude findings of additional cost exceptions issued as the result of an audit.

(C) Calculation of interim payment rates.

(1) Interim payment rates for each state-operated ICF-MR shall be based upon the source data described in paragraph (B) of this rule.

(2) The interim payment rate shall be calculated as follows:

(a) Calculation of direct care per diem rate.

(i) Calculate the direct care per diem for each state-operated ICF-MR by dividing direct care costs by total inpatient days.

(ii) For each facility multiply the facility's direct care per diem by the facility's inpatient days. Sum results for all facilities and divide by the sum of inpatient days for all facilities.

(iii) Calculate the direct care per diem ceiling by taking the amount calculated in paragraph (C)(2)(a)(ii) of this rule and multiplying it by one hundred twelve per cent.

(iv) The interim state-operated ICF-MR direct care per diem will be the lower of the amount calculated in paragraph (C)(2)(a)(i) of this rule or the direct care per diem ceiling as calculated in paragraph (C)(2)(a)(iii) of this rule.

(b) Calculate the ancillary cost per diem for each state-operated ICF-MR by dividing ancillary costs by total inpatient days.

(c) Calculate the capital cost per diem for each state-operated ICF-MR by dividing capital costs by total inpatient days.

(d) The interim payment rate for each state-operated ICF-MR shall be the sum of the amounts calculated in paragraphs (C)(2)(a)(iv), (C)(2)(b) and (C)(2)(c) of this rule, inflated from the mid-point of the base year to the midpoint of the rate year using the skilled nursing facility (SNF) market basket as calculated by "Global Insight" or a successor firm, and submitted to ODJFS by March thirty-first, before the beginning of the new rate year.

(3) For periods after SFY 2007, a state-operated ICF-MR certified after June 30, 2003 whose cost report includes less than twelve months of complete data shall be reimbursed the statewide average interim payment rate for state-operated ICFs-MR calculated for that rate year by summing the rates for each state-operated ICF-MR as described in paragraph (C)(2)(d) of this rule and dividing by the number of state-operated ICFs-MR. Interim payment rates are subject to final settlement as included in paragraph (E) of this rule.

(4) Notwithstanding paragraph (C)(1) of this rule, for the period starting on July 1, 2005 and ending on December 31, 2005 only, the interim payment rate shall be adjusted to arrive at the adjusted interim payment rate for each facility by the following process.

(a) ODMRDD shall determine, by facility, the number of residents of state-operated ICFs-MR who received off-site day habilitation services/active treatment services in SFY 2004. This shall be referred to as the facility specific residency count used in calculating the adjusted interim payment rate.

(b) ODMRDD shall multiply the facility-specific residency count determined under paragraph (C)(4)(a) of this rule by no more than one hundred thirty or a similar estimate of the number of daily units of off-site day habilitation services/active treatment services that each resident of a state-operated ICFs-MR, who receives off-site day habilitation services/active treatment services, will receive between July 1, 2005 and December 31, 2005. This shall be referred to as the six-month projected daily units used in calculating the adjusted interim payment rate.

(c) ODMRDD shall multiply the product calculated under paragraph (C)(4)(b) of this rule by the county-specific rates from appendix B of this rule that are applicable to the counties in which state-operated ICFs-MR are located.

(d) ODMRDD shall divide the product calculated under paragraph (C)(4)(c) of this rule by total inpatient days for SFY 2004 as reported by each state-operated ICF-MR on the JFS 01984 cost reports for the period January 1, 2004 to June 30, 2004.

(e) ODMRDD shall add the quotient calculated under paragraph (C)(4)(d) of this rule to the interim payment rates for each facility.

(f) The adjustment process set forth in paragraph (C)(4) of this rule shall apply exclusively to periods between July 1, 2005 and December 31, 2005, and shall not be used for adjustments for any other period. The additional amount to be paid in the rate for off-site day habilitation/active treatment and associated transportation services shall not be subject to the direct care per diem ceiling calculated in accordance with paragraph (C)(2)(a)(iii) of this rule.

(5) Notwithstanding paragraph (C)(1) of this rule, for the period starting on January 1, 2006 and ending on June 30, 2007 only, the interim payment rate shall be adjusted to arrive at the adjusted interim payment rate for each facility by the following process.

(a) ODMRDD shall for each facility, multiply the six month projected daily units determined under paragraph (C)(4)(b) of this rule by three and then by the county-specific rates in appendix B of this rule . The rates in appendix B to this rule may be amended to reflect revised rates approved by CMS. The rate applicable to a county where the state-operated ICF-MR is located shall be used for determining the rate used for this purpose.

(b) ODMRDD shall divide the product calculated under paragraph (C)(5)(a) of this rule by one-and a half times the total inpatient days for SFY 2004 as reported on the JFS 01984 cost report for each facility to arrive at the adjusted interim payment rate.

(c) ODMRDD shall add the quotient calculated under paragraph (C)(5)(b) of this rule to the interim direct care per diem rate to arrive at the adjusted interim payment rate. The additional amount to be paid in the rate for off-site day habilitation/active treatment and associated transportation services shall not be subject to the direct care per diem ceiling calculated in accordance with paragraph (C)(2)(a)(iii) of this rule.

(d) The adjustment process set forth in paragraph (C)(5) of this rule shall apply exclusively to periods between January 1, 2006 and June 30, 2007, and shall not be used for adjustments for any other period.

(6) Effective for the period of July 1, 2005 to December 31, 2005, the amount included in the JFS 01984 cost report shall be the rate paid to off-site providers of day habilitation/active treatment and associated transportation services limited to no more than the county specific rate included in appendix B of this rule times actual units of service.

(7) Effective for the period of January 1, 2006 to September 30, 2006, the amount included in the JFS 01984 cost report for payments to off-site providers of day habilitation/active treatment and associated transportation services shall be limited to the lower of:

(a) The county specific rate included in appendix B to this rule times actual units of service; or

(b) Where a state operated ICF-MR is in the same county where a non-developmental center/private ICF-MR contracts with a county board of ODMRDD for off-site day habilitation/active treatment and related transportation services, the facility shall be limited to no more than the lowest contracted daily rate as included in a contract in effect during the corresponding fiscal year times the actual units of service provided; or

(c) In those counties where no non developmental center private ICF-MR has a contract to provide services for consumers of a county board of MRDD for offsite day habilitation/active treatment and associated transportation services, the rate shall be limited to the county specific rates in appendix B to this rule times the actual units of services provided.

(8) Effective for the period of October 1, 2006 to June 30, 2007, the amount included in the JFS 01984 cost report for payments to off-site providers of day habilitation/active treatment and associated transportation service shall be limited to the lower of:

(a) The county specific rate included in appendix B to this rule times actual units of service; or

(b) Eighty-seven dollars times actual units of service.

(9) For SFY 2006 and 2007 only, each state-operated ICF-MR certified after June 30, 2003 whose cost report includes less than twelve months of complete data shall be reimbursed the statewide average interim payment rate for state-operated ICFs-MR plus an additional amount to be paid in the rate for off-site day habilitation/active treatment and associated transportation services as calculated in paragraphs (C)(4) and (C)(5) of this rule. When the calculation requiring the use of SFY 2004 inpatient days in paragraph (C)(4)(d) or (C)(5)(b) of this rule does not apply then an estimate of inpatient days shall be used.

(10) A state-operated ICF-MR certified cost report shall be filed within one hundred eighty days of the end of the fiscal year. If the cost report is not received within one hundred eighty days of the end of the fiscal year the rate paid will be the lower of ninety per cent of the state wide average or the current rate.

(D) Audit.

(1) ODJFS will perform field audits of the most current cost report for each state-operated ICFs-MR at least once every three years. Cost reports for other periods may also be audited as determined necessary by the ODJFS. The audits will be performed in accordance with auditing standards adopted by the ODJFS. To determine which state-operated ICFs-MR are subject to audit, ODJFS will develop a risk-based methodology.

(2) The audit scope will be determined by the ODJFS and will be sufficient to determine if costs reflected in the cost report are accurate, made in compliance with pertinent regulations, and based on actual cost.

(3) ODMRDD must maintain documentation to support all transactions, to permit the reconstruction of all transactions and the proper completion of all reports required by state and federal laws and regulations, and to substantiate compliance with all applicable federal statutes or regulations, state statutes or administrative rules. This documentation must be maintained for the greater of seven years after the cost report is filed or, if ODJFS issues an audit report, six years after all appeal rights relating to the audit report are exhausted. ODMRDD must make available to the ODJFS personnel all records necessary to document all transactions, regardless of where records are maintained. Accounting records must include sufficient detail to disclose:

(a) Services provided; and

(b) Administrative costs of services provided; and

(c) Costs of operating the organizations, agencies, program, activities, and functions; and

(d) Accuracy of inpatient days; and

(e) Services claimed are covered under the medicaid program and made in accordance with applicable rules of the Administrative Code; and

(f) Amounts of third-party payments reported are indicative of actual amounts received; and

(g) Costs reported to the ODJFS represent actual incurred, reasonable, and allowable costs in accordance with provisions of the CMS provider manual 15-1, Chapter 5101:3-3 of the Administrative Code as applicable, and 45 CFR 92 dated October 1, 2000.

(4) Each facility shall collect, report, and maintain separately all data and records sufficient to support the rate calculation including but not limited to statistical and financial data:

(a) Related to costs that are included in or listed in the cost report as reimbursable costs; and

(b) Relate to non-reimbursable costs; and

(c) Related to the contracted rate, amount, time period of those contracts between private ICFs-MR and county boards of MRDD as included in paragraph (C)(6)(a) of this rule; and

(d) Necessary to support the use of the rate schedule referenced in paragraph (C)(5)(a) of this rule.

(5) ODJFS shall recognize costs subject to this rule as evidenced through executed contracts for off-site day habilitation/active treatment and associated transportation services which comply with paragraphs (C)(6)(a) and (C)(6)(b) of this rule. Where records and data are not available or not provided on request, those costs shall be excluded from the JFS 01984 cost report.

(6) ODMRDD must maintain adequate systems of internal control as related to federal funding to ensure:

(a) Accurate and reliable financial and administrative records; and

(b) Efficient and effective use of resources; and

(c) Compliance with pertinent laws and regulations.

(E) Final settlement.

(1) Final settlement is the process where allowable and reasonable costs included in the rate year cost report are used to establish a final payment rate that is reconciled to the interim payment rate.

(2) The rate year cost report shall include adjustments included in paragraphs (B)(2) and (D)(1) to (D)(5) of this rule.

(3) The final payment rate shall be calculated as follows:

(a) Calculation of direct care per diem rate.

(i) Calculate the direct care per diem for each state-operated ICF-MR by dividing direct care costs by total inpatient days as described in paragraph (A) of this rule.

(ii) For each facility multiply the facility's direct care per diem by the facility's inpatient days as described in paragraph (A) of this rule. Sum results for all facilities and divide by the sum of inpatient days for all facilities.

(iii) Calculate the direct care per diem ceiling by taking the amount calculated in paragraph (E)(3)(a)(ii) of this rule and multiplying it by one hundred twelve per cent.

(iv) The final state-operated ICF-MR direct care per diem will be the lower of the amount calculated in paragraph (E)(3)(a)(i) of this rule or the direct care per diem ceiling as calculated in paragraph (E)(3)(a)(iii) of this rule.

(b) Calculate the ancillary cost per diem for each state-operated ICF-MR by dividing ancillary costs by total inpatient days as described in paragraph (A) of this rule.

(c) Calculate the capital cost per diem for each state-operated ICF-MR by dividing capital costs by total inpatient days as described in paragraph (A) of this rule. The final rate for each state-operated ICF-MR shall be the sum of the amounts calculated in paragraphs (E)(2)(a)(iv), (E)(2)(b) and (E)(2)(c) of this rule.

(d) Calculation of the additional amount paid for off-site day habilitation/active treatment and associated transportation services for SFY 2006 and 2007 only for each state operated facility.

(i) For the period July 1, 2005 to December 30, 2005, divide the allowable costs as restricted by paragraph (C)(6) of this rule by total inpatient days described in paragraph (A) of this rule for July 1, 2005 to December 30, 2005.

(ii) For the period January 1, 2006 to June 30, 2006, divide the allowable costs as restricted by paragraph (C)(7) of this rule by total inpatient days described in paragraph (A) of this rule for January 1, 2006 to June 30, 2006.

(iii) For SFY 2006, add the quotients calculated in paragraphs (E)(3)(d)(i) and (E)(3)(d)(ii) of this rule.

(iv) For the period July 1, 2006 to September 30, 2006, divide the allowable costs as restricted by paragraph (C)(7) of this rule by total inpatient days described in paragraph (A) of this rule for July 1, 2006 to September 30, 2006.

(v) For the period October 1, 2006 to June 30, 2007, divide the allowable costs as restricted by paragraph (C)(8) of this rule by total inpatient days described in paragraph (A) of this rule for October 1, 2006 to June 30, 2007.

(vi) For SFY 2007, add the quotients calculated in paragraphs (E)(3)(d)(iv) and (E)(3)(d)(v) of this rule.

(4) The final payment rate calculated in paragraph (E)(3) of this rule is subtracted from the interim payment rate calculated in paragraph (C)(2) or (C)(3) of this rule, as applicable. The result is multiplied by the paid days and applicable federal financial participation (FFP) rate. The result of this calculation is the final settlement amount. Where the interim rate exceeds the final rate, the excess payment shall be remitted to ODJFS. If the final rate exceeds the interim rate, ODJFS shall remit the amount to ODMRDD.

(5) For periods after SFY 2007, the final payment rate calculated in paragraph (E)(3) of this rule is subtracted from the adjusted interim payment rate calculated in paragraphs (C)(4), (C)(5) and (C)(7) of this rule, as applicable. The result is multiplied by the paid days and applicable FFP rate. The result of this calculation is the final settlement amount. Where the adjusted interim rate exceeds the final rate, the excess payment shall be remitted to ODJFS. If the final rate exceeds the interim rate, ODJFS shall remit the amount to ODMRDD. The costs incurred for providing the off-site day program/active treatment and transportation services are included when calculating the direct care ceiling for the purposes of final settlement.

(6) The audit and final settlement shall be issued within thirty-six months of receipt of the cost report for the rate year. If an audit is not issued for final settlement within thirty-six months, the rates calculated using the desk reviewed rate year cost report shall be used for final settlement.

(7) No further adjustments to payments or rates can occur after the implementation of the final cost settlement.

(F) Upper payment limit assurance.

Payments made to state-operated ICFs-MR in accordance with this rule under medicaid are, in the aggregate on a statewide basis, equal to or less than amounts which would have been recognized under Title XVIII (medicare) for comparable services in accordance with 42 CFR 447.272 effective October 31, 2000, and available at www.cms.hhs.gov.

(G) Dispute resolution.

All disputes regarding the application of this rule, including but not limited to desk reviews, payment, rate setting, and audits shall be resolved between ODJFS and ODMRDD in accordance with terms set forth in the interagency agreement. Disputes that arise from the application of this rule shall not be subject to hearings conducted under Chapter 119. of the Revised Code.

(H) Rule exclusion.

Excluding those rules referring to reasonableness ceilings, cost limitations, cost reimbursement, occupancy levels, disallowance of costs, payment calculations, payment methodology, and appeals, all other rules which govern the operation of medicaid-certified intermediate care facilities for the mentally retarded under Chapters 5101:3-1 and 5101:3-3 of the Administrative Code shall apply to state-operated ICFs-MR. The payment methodology specified in this rule shall govern the reimbursement of medicaid costs for state-operated ICFs-MR.

Appendix A Developmental Center Report

Ohio Department of Job and Family Services

Developmental Center Name: _______________

Building Name/Cottage Name Building Number/Cottage Number Provider Number/NPI

Building 1

Building 2

Building 3

Building 4

Building 5

Building 6

Building 7

Building 8

Building 9

Building 10

Building 11

Building 12

COST REPORTING PERIOD

FISCAL YEAR: _________

July 1, _____ - June 30, _____

STATUS: ________________

JFS 01984 (2/2004)

Appendix B Adult Day Habilitation Costs

COUNTY ADULT DAY HABILITATION UNIT

ADAMS $ 60.62 Per Day

ALLEN $ 73.92 Per Day

ASHLAND $ 85.01 Per Day

ASHTABULA $ 76.90 Per Day

ATHENS $ 108.57 Per Day

AUGLAIZE $ 60.62 Per Day

BELMONT $ 80.18 Per Day

BROWN $ 56.83 Per Day

BUTLER $ 116.85 Per Day

CARROLL $ 84.02 Per Day

CHAMPAIGN $ 80.18 Per Day

CLARK $ 76.84 Per Day

CLERMONT $ 101.60 Per Day

CLINTON $ 76.84 Per Day

COLUMBIANA $ 80.18 Per Day

COSHOCTON $ 88.35 Per Day

CRAWFORD $ 55.90 Per Day

CUYAHOGA $ 106.04 Per Day

DARKE $ 66.80 Per Day

DEFIANCE $ 112.41 Per Day

DELAWARE $ 129.28 Per Day

ERIE $ 88.46 Per Day

FAIRFIELD $ 91.50 Per Day

FAYETTE $ 66.88 Per Day

FRANKLIN $ 107.55 Per Day

FULTON $ 121.00 Per Day

GALLIA $ 66.88 Per Day

GEAUGA $ 80.18 Per Day

GREENE $ 96.63 Per Day

GUERNSEY $ 84.02 Per Day

HAMILTON $ 97.76 Per Day

HANCOCK $ 84.02 Per Day

HARDIN $ 63.54 Per Day

HARRISON $ 73.06 Per Day

HENRY $ 112.41 Per Day

HIGHLAND $ 73.06 Per Day

HOCKING $ 60.62 Per Day

HOLMES $ 108.57 Per Day

HURON $ 37.38 Per Day

JACKSON $ 42.82 Per Day

JEFFERSON $ 80.18 Per Day

KNOX $ 69.72 Per Day

LAKE $ 143.59 Per Day

LAWRENCE $ 38.24 Per Day

LICKING $ 101.60 Per Day

LOGAN $ 92.19 Per Day

LORAIN $ 76.84 Per Day

LUCAS $ 101.60 Per Day

MADISON $ 76.84 Per Day

MAHONING $ 88.35 Per Day

MARION $ 73.92 Per Day

MEDINA $ 101.60 Per Day

MEIGS $ 55.25 Per Day

MERCER $ 73.06 Per Day

MIAMI $ 108.57 Per Day

MONROE $ 66.88 Per Day

MONTGOMERY $ 116.85 Per Day

MORGAN $ 69.79 Per Day

MORROW $ 88.46 Per Day

MUSKINGUM $ 46.50 Per Day

NOBLE $ 66.88 Per Day

OTTAWA $ 108.57 Per Day

PAULDING $ 61.51 Per Day

PERRY $ 58.17 Per Day

PICKAWAY $ 92.19 Per Day

PIKE $ 45.85 Per Day

PORTAGE $ 121.00 Per Day

PREBLE $ 76.90 Per Day

PUTNAM $ 52.73 Per Day

RICHLAND $ 80.18 Per Day

ROSS $ 92.19 Per Day

SANDUSKY $ 43.98 Per Day

SCIOTO $ 92.19 Per Day

SENECA $ 69.72 Per Day

SHELBY $ 82.09 Per Day

STARK $ 92.19 Per Day

SUMMIT $ 127.77 Per Day

TRUMBULL $ 106.04 Per Day

TUSCARAWAS $ 88.46 Per Day

UNION $ 88.35 Per Day

VAN WERT $ 53.49 Per Day

VINTON $ 32.88 Per Day

WARREN $ 106.04 Per Day

WASHINGTON $ 69.72 Per Day

WAYNE $ 88.46 Per Day

WILLIAMS $ 112.41 Per Day

WOOD $ 134.36 Per Day

WYANDOT $ 37.38 Per Day

Effective: 04/17/2008
R.C. 119.032 review dates: 11/13/2007 and 04/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.291
Prior Effective Dates: 8/1/02, 7/1/04, 7/1/05(Emer), 9/29/05, 10/1/06